Effect of Neutralizing Monoclonal Antibody Treatment on Early Trajectories of Virologic and Immunologic Biomarkers in Patients Hospitalized With COVID-19

BACKGROUND

Neutralizing monoclonal antibodies (nmAbs) failed to show clear benefit for hospitalized patients with coronavirus disease 2019 (COVID-19). Dynamics of virologic and immunologic biomarkers remain poorly understood.

METHODS

Participants enrolled in the Therapeutics for Inpatients with COVID-19 trials were randomized to nmAb versus placebo. Longitudinal differences between treatment and placebo groups in levels of plasma nucleocapsid antigen (N-Ag), anti-nucleocapsid antibody, C-reactive protein, interleukin-6, and D-dimer at enrollment, day 1, 3, and 5 were estimated using linear mixed models. A 7-point pulmonary ordinal scale assessed at day 5 was compared using proportional odds models.

RESULTS

Analysis included 2149 participants enrolled between August 2020 and September 2021. Treatment resulted in 20% lower levels of plasma N-Ag compared with placebo (95% confidence interval, 12%-27%; P < .001), and a steeper rate of decline through the first 5 days (P < .001). The treatment difference did not vary between subgroups, and no difference was observed in trajectories of other biomarkers or the day 5 pulmonary ordinal scale.

CONCLUSIONS

Our study suggests that nmAb has an antiviral effect assessed by plasma N-Ag among hospitalized patients with COVID-19, with no blunting of the endogenous anti-nucleocapsid antibody response. No effect on systemic inflammation or day 5 clinical status was observed.

CLINICAL TRIALS REGISTRATION

NCT04501978.

Adult and paediatric haematology and clinical chemistry laboratory reference limits for Liberia

Background

As more research is conducted in Liberia, there is a need for laboratory reference limits for common chemistry and haematology values based on a healthy population. Reference limits from the United States may not be applicable.

Objective

The aim of this study was to present laboratory reference ranges from a Liberian population and compare them to United States ranges.

Methods

Serum chemistry and haematology values from 2529 adults and 694 children and adolescents obtained from two studies conducted in Liberia between 2015 to 2017 were used to determine reference limits. After removing outliers, the reference limits defined by the 2.5th and 97.5th percentiles were determined by sex in three age groups (6–11, 12–17, and 18+ years).

Results

The median (interquartile range) of adults was 29 (23, 37) years; 44% were female. The median (interquartile range) for children and adolescents was 12 (9, 15) years; 53% were female. Several reference ranges determined using Liberian participants differed from those in the US. For chemistries, a high percentage of both adults and children/adolescents had high serum chloride levels based on United States ranges. For haematology, a high percentage of Liberian participants had haemoglobin and related assays below the lower limit of United States ranges.

Conclusion

Chemistry and haematology reference intervals determined for a Liberian population of healthy individuals should be considered for establishing eligibility criteria and monitoring of laboratory adverse events for clinical trials as well as for use in clinical settings in Liberia and perhaps for other countries in Western Africa.

Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/μL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial.

METHODS

QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors.

RESULTS

A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence.

CONCLUSIONS

In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.

Chlorhexidine-Impregnated Cloths to Prevent Skin and Soft-Tissue Infection in Marine Recruits: A Cluster-Randomized, Double-Blind, Controlled Effectiveness Trial

Background.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) causes skin and soft-tissue infection (SSTI) in military recruits.

Objective.

To evaluate the effectiveness of 2% Chlorhexidine gluconate (CHG)-impregnated cloths in reducing rates of SSTI and S. aureus colonization among military recruits.

Design.

A cluster-randomized (by platoon), double-blind, controlled effectiveness trial.

Setting.

Marine Officer Candidate School, Quantico, Virginia, 2007.

Participants.

Military recruits.

Intervention.

Application of CHG-impregnated or control (Comfort Bath; Sage) cloths applied over entire body thrice weekly.

Measurements.

Recruits were monitored daily for SSTI. Baseline and serial nasal and/or axillary swabs were collected to assess S. aureus colonization.

Results.

Of 1,562 subjects enrolled, 781 (from 23 platoons) underwent CHG-impregnated cloth application and 781 (from 21 platoons) underwent control cloth application. The rate of compliance (defined as application of 50% or more of wipes) at 2 weeks was similar (CHG group, 63%; control group, 67%) and decreased over the 6-week period. The mean 6-week SSTI rate in the CHG-impregnated cloth group was 0.094, compared with 0.071 in the control group (analysis of variance model rate difference, 0.025 ± 0.016; P = .14). At baseline, 43% of subjects were colonized with methicillin-susceptible S. aureus (MSSA), and 2.1% were colonized with MRSA. The mean incidence of colonization with MSSA was 50% and 61% (P = .026) and with MRSA was 2.6% and 6.0% (P = .034) for the CHG-impregnated and control cloth groups, respectively.

Conclusions.

CHG-impregnated cloths applied thrice weekly did not reduce rates of SSTI among recruits. S. aureus colonization rates increased in both groups but to a lesser extent in those assigned to the CHG-impregnated cloth Intervention. Antecedent S. aureus colonization was not a risk factor for SSTI. Additional studies are needed to identify effective measures for preventing SSTI among military recruits.

Clinical Trials Registration.

ClinicalTrials.gov identifier: NCT00475930.

Marine recruit adherence in a skin and soft tissue infection prevention trial: implications for recruit research and public health application

A cluster-randomized trial evaluating the effectiveness of chlorhexidine gluconate-impregnated wipes against skin and soft tissue infections (SSTIs) and colonization with methicillin-resistant Staphylococcus aureus (MRSA) was conducted among military recruits attending Officer Candidate School at Marine Corps Base Quantico, Virginia. Participants were instructed to use the wipes thrice weekly and were monitored daily for SSTI. Surveys assessed frequency of wipe use as well as knowledge and attitudes regarding MRSA SSTI. Use of chlorhexidine gluconate-impregnated wipes failed to prevent SSTI; however, study adherence was moderate. Adherence with the study regimen (defined as use of > or = 50% of the wipes) was 65% at week 2 and declined to 49% by week 6. Adherence was approximately 59% in the first two classes and declined in later classes. One-third felt that use of the wipes was disruptive. Participants were knowledgeable about MRSA SSTI prevention measures. However, only 53% agreed that MRSA commonly causes skin infections in military training facilities. Understanding adherence and its determinants is needed to optimize prevention strategies that require self-administration. Future efforts should address barriers to adherence with prevention strategies in recruit training settings.

The impact of enzyme-inducing antiepileptic drugs on antiretroviral drug levels: a case-control study

PURPOSE

To evaluate the impact of enzyme-inducing antiepileptic drugs (EI-AEDs) on serum antiretroviral (ARV) levels in patients with HIV.

METHODS

Data from the U.S. Military HIV Natural History Study were screened to identify participants taking ARVs with EI-AEDs and controls taking ARVs with non enzyme-inducing AEDs (NEI-AEDs). The proportion of serum ARV levels below the recommended minimum concentrations (C(min)) was compared between these groups.

RESULTS

ARV levels were available for 10 individuals exposed to 16 intervals on combined ARVs/EI-AEDs (phenytoin and carbamazepine) and for 25 controls exposed to 30 overlap intervals on combined ARVs/NEI-AEDs. The percentage of overlap intervals with ≥1 ARV levels below C(min) was higher in the EI-AED group than in controls (37.5% vs. 23.3%; p=0.124). After excluding intervals associated with serum levels of EI-AEDs below the reference range (n=6), the proportion of intervals with ≥1 ARV level below C(min) was significantly greater among EI-AED recipients (60%) compared to controls (23.3%; p=0.008).

CONCLUSIONS

ARV levels below C(min) were more common in participants receiving EI-AEDs, the difference being statistically significant for intervals associated with EI-AED levels within the reference range. These data suggest that, in agreement with current guidelines, EI-AEDs should be avoided in patients receiving ARV therapy.

Chlorhexidine gluconate reduces transmission of methicillin-resistant Staphylococcus aureus USA300 among Marine recruits

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) pulsed-field type (PFT) USA300 causes skin and soft tissue infections in military recruits and invasive disease in hospitals. Chlorhexidine gluconate (CHG) is used to reduce MRSA colonization and infection. The impact of CHG on the molecular epidemiology of MRSA is not known.

OBJECTIVE

To evaluate the impact of 2% CHG-impregnated cloths on the molecular epidemiology of MRSA colonization.

DESIGN

Cluster-randomized, double-blind, controlled trial.

SETTING

Marine Officer Candidate School, Quantico, Virginia, in 2007.

PARTICIPANTS

Military recruits.

INTERVENTION

Thrice-weekly application of CHG-impregnated or control (Comfort Bath; Sage) cloths over the entire body.

MEASUREMENTS

Baseline and serial (every 2 weeks) nasal and/or axillary swab samples were assessed for MRSA colonization. Molecular analysis was performed with pulsed-field gel electrophoresis.

RESULTS

During training, 77 subjects (4.9%) acquired MRSA, 26 (3.3%) in the CHG group and 51 (6.5%) in the control group (P=.004). When analyzed for PFT, 24 subjects (3.1%) in the control group but only 6 subjects (0.8%) in the CHG group (P=.001) had USA300. Of the 167 colonizing isolates recovered from 77 subjects, 99 were recovered from the control group, including USA300 (40.4%), USA800 (38.4%), USA1000 (12.1%), and USA100 (6.1%), and 68 were recovered from the CHG group, including USA800 (51.5%), USA100 (23.5%), and USA300 (13.2%).

CONCLUSIONS

CHG decreased the transmission of MRSA--more specifically, USA300--among military recruits. In addition, USA300 and USA800 outcompeted other MRSA PFTs at incident colonization. Future studies should evaluate the broad-based use of CHG to decrease transmission of USA300 in hospital settings.

Spontaneous virologic suppression in HIV controllers is independent of delayed-type hypersensitivity test responsiveness

Background

Delayed-type hypersensitivity (DTH) testing, an in vivo assessment of cell-mediated immunity, is a predictor of HIV disease progression beyond CD4 cell count. We investigated whether preserved DTH responsiveness was characteristic of HIV controllers compared to non-controllers and individuals on suppressive HAART.

Findings

DTH testing consisted of ≥ 3 recall antigens applied approximately every 6 months. DTH responses were classified by the number of positive skin tests: anergic (0), partial anergic (1), or non-anergic (≥ 2). HIV controllers were compared to treatment naïve non-controllers (n = 3822) and a subgroup of non-controllers with VL < 400 copies/mL on their initial HAART regimen (n = 491). The proportion of non-anergic results at first DTH testing was similar for HIV controllers compared to non-controllers (81.9% vs. 77.6%; P = 0.22), but tended to be greater in HIV controllers compared to the HAART subgroup (81.9% vs. 74.5%; P = 0.07). Complete anergy was observed in 14 (10.1%) HIV controllers with CD4 counts ≥ 400 cells/uL. For longitudinal testing, the average percentage of non-anergic DTH determinations per participant was higher in HIV controllers compared to non-controllers (81.2 ± 31.9% vs. 70.7 ± 36.8%; P = 0.0002), however this difference was eliminated with stratification by CD4 count: 200-399 (83.4 ± 35.6% vs. 71.9 ± 40.9%; P = 0.15) and > 400 cells/uL (81.2 ± 31.5% vs. 80.4 ± 32.7%; P = 0.76).

Conclusions

Spontaneous virologic control was not associated with DTH responsiveness, and several HIV controllers were anergic despite having elevated CD4 counts. These findings suggest that cellular immunity assessed by DTH is not a principal factor contributing to spontaneous virologic suppression in HIV controllers.

Virologic outcomes of HAART with concurrent use of cytochrome P450 enzyme-inducing antiepileptics: a retrospective case control study

BACKGROUND

To evaluate the efficacy of highly-active antiretroviral therapy (HAART) in individuals taking cytochrome P450 enzyme-inducing antiepileptics (EI-EADs), we evaluated the virologic response to HAART with or without concurrent antiepileptic use.

METHODS

Participants in the US Military HIV Natural History Study were included if taking HAART for ≥6 months with concurrent use of EI-AEDs phenytoin, carbamazepine, or phenobarbital for ≥28 days. Virologic outcomes were compared to HAART-treated participants taking AEDs that are not CYP450 enzyme-inducing (NEI-AED group) as well as to a matched group of individuals not taking AEDs (non-AED group). For participants with multiple HAART regimens with AED overlap, the first 3 overlaps were studied.

RESULTS

EI-AED participants (n = 19) had greater virologic failure (62.5%) compared to NEI-AED participants (n = 85; 26.7%) for the first HAART/AED overlap period (OR 4.58 [1.47-14.25]; P = 0.009). Analysis of multiple overlap periods yielded consistent results (OR 4.29 [1.51-12.21]; P = 0.006). Virologic failure was also greater in the EI-AED versus NEI-AED group with multiple HAART/AED overlaps when adjusted for both year of and viral load at HAART initiation (OR 4.19 [1.54-11.44]; P = 0.005). Compared to the non-AED group (n = 190), EI-AED participants had greater virologic failure (62.5% vs. 42.5%; P = 0.134), however this result was only significant when adjusted for viral load at HAART initiation (OR 4.30 [1.02-18.07]; P = 0.046).

CONCLUSIONS

Consistent with data from pharmacokinetic studies demonstrating that EI-AED use may result in subtherapeutic levels of HAART, EI-AED use is associated with greater risk of virologic failure compared to NEI-AEDs when co-administered with HAART. Concurrent use of EI-AEDs and HAART should be avoided when possible.

Long-term safety and serologic response to measles, mumps, and rubella vaccination in HIV-1 infected adults

We analyzed HIV viral load (VL) and CD4 count changes, and antibody responses following MMR vaccination of individuals in the U.S. Military HIV Natural History Study cohort. Cases receiving at least one dose of MMR vaccine after HIV diagnosis were matched 1:2 to HIV-positive controls not receiving the vaccine. Baseline was defined as time of vaccination for cases and indexed and matched to the time post-HIV diagnosis for controls. Changes in CD4 count and VL at 6, 12, 18 and 24 months were compared between cases and controls using a general linear model. Available sera from cases were tested for MMR seropositivity at baseline and post-vaccination at 6, 12, 18, and 24 months. Overall mean CD4 count change from baseline through 24 months was 20 (±23) cells/μL greater for cases than controls (p=0.39). Similar non-significant changes in CD4 cell count were seen in the subset of those not on HAART at baseline. VL changes were small and similar between groups (mean differential change -0.04 (±0.18) log(10) copies/mL; p=0.84). Of 21 vaccinated participants with baseline serologic testing, 14 (67%) were reactive to measles, 19 (91%) to mumps, and 20 (95%) to rubella. Three (43%) of 7 participants nonreactive to measles developed measles IgG; for mumps, 1 (50%) of 2 developed mumps IgG; for rubella, 1 (100%) developed rubella IgG. MMR vaccination did not result in detrimental immunologic or virologic changes through 24 months post-vaccination.

CD4 T cell count reconstitution in HIV controllers after highly active antiretroviral therapy

Sixty-two human immunodeficiency virus (HIV) controllers (6 elite and 56 viremic controllers) in the US Military Department of Defense HIV Natural History Study cohort initiated highly active antiretroviral therapy (HAART) and achieved statistically significant mean CD4 cell count increases, although the gains were lower than those in treated noncontrollers. HIV controllers experienced CD4 cell count reconstitution with HAART regardless of pretherapy viral load, including patients with undetectable viral loads at HAART initiation.

Outcomes of highly active antiretroviral therapy in the context of universal access to healthcare: the U.S. Military HIV Natural History Study

Background

To examine the outcomes of highly-active antiretroviral therapy (HAART) for individuals with free access to healthcare, we evaluated 2327 patients in a cohort study composed of military personnel and beneficiaries with HIV infection who initiated HAART from 1996 to the end of 2007.

Methods

Outcomes analyzed were virologic suppression (VS) and failure (VF), CD4 count changes, AIDS and death. VF was defined as never suppressing or having at least one rebound event. Multivariate (MV) analyses stratified by the HAART initiation year (before or after 2000) were performed to identify risk factors associated with these outcomes.

Results

Among patients who started HAART after 2000, 81% had VS at 1 year (N = 1,759), 85% at 5 years (N = 1,061), and 82% at 8 years (N = 735). Five years post-HAART, the median CD4 increase was 247 cells/ml and 34% experienced VF. AIDS and mortality rates at 5 years were 2% and 0.3%, respectively. In a MV model adjusted for known risk factors associated with treatment response, being on active duty (versus retired) at HAART initiation was associated with a decreased risk of AIDS (HR = 0.6, 95% CI 0.4-1.0) and mortality (0.6, 0.3-0.9), an increased probability of CD4 increase ≥ 50% (1.2, 1.0-1.4), but was not significant for VF.

Conclusions

In this observational cohort, VS rates approach those described in clinical trials. Initiating HAART on active duty was associated with even better outcomes. These findings support the notion that free access to healthcare likely improves the response to HAART thereby reducing HIV-related morbidity and mortality.

Association of Single Measurements of Dipstick Proteinuria, Estimated Glomerular Filtration Rate, and Hematocrit with 25-Year Incidence of End-Stage Renal Disease in the Multiple Risk Factor Intervention Trial

The incidence of ESRD is increasing rapidly. Limited information exists regarding early markers for the development of ESRD. This study aimed to determine over 25 yr the risk for ESRD associated with proteinuria, estimated GFR (eGFR), and hematocrit in men who did not have identified kidney disease and were randomly assigned into the Multiple Risk Factor Intervention Study (MRFIT). A total of 12,866 men who were at high risk for heart disease were enrolled (1973 to 1975) and followed through 1999. Renal replacement therapy was ascertained by matching identifiers with the United States Renal Data System's data; vital status was from the National Death Index. Men who initiated renal replacement therapy or died as a result of kidney disease were deemed to have developed ESRD. Dipstick urine for proteinuria, eGFR, and hematocrit were related to development of ESRD. During 25 yr, 213 (1.7%) men developed ESRD. Predictors of ESRD were dipstick proteinuria of 1+ or > or =2+ (hazard ratio [HR] 3.1 [95% confidence interval (CI) 1.8 to 5.4] and 15.7 [95% CI 10.3 to 23.9] respectively) and an eGFR of <60 ml/min per 1.73 m(2) (HR 2.4; 95% CI 1.5 to 3.8). Correlation between eGFR and serum creatinine was 0.9; the risk for ESRD with a 1-SD difference of each was identical (HR 1.21). Bivariate analysis demonstrated a 41-fold increase in ESRD risk in those with an eGFR <60 ml/min per 1.73 m(2) and > or =2+ proteinuria (95% CI 15.2 to 71.1). There was no association between hematocrit and ESRD. Other baseline measures that independently predicted ESRD included age, cigarette smoking, BP, low HDL cholesterol, and fasting glucose. Among middle-aged men who were at high risk for cardiovascular disease but had no clinical evidence of cardiovascular disease or significant kidney disease, dipstick proteinuria and an eGFR value <60 ml/min per 1.73 m(2) were strong predictors of long-term development of ESRD. It remains unknown whether intervention for proteinuria or early identification of those with chronic kidney disease reduces the risk for ESRD.

Obtaining event status at the close of the Treatment of Mild Hypertension Study: methods and implication for other trials

The Treatment of Mild Hypertension Trial was a randomized, double-blind clinical trial conducted from 1986 to 1992 comparing the efficacy of six antihypertensive treatment regimens in 902 participants with stage I hypertension. To satisfy a secondary objective of the study, follow-up information on mortality and cardiovascular morbidity was collected. For this objective the aim was to ascertain the vital and cardiovascular event status as of the last day of the trial. This was accomplished by inviting each participant to attend a closeout visit shortly after the closeout date. In addition to serving as verification of vital status, this visit allowed data collection on nonfatal events that occurred between the last clinic visit and the closeout date. During this visit the patient was unblinded to study medication and given a medical summary of their participation during the trial, as well as a bottle of open-label medication. The advantages of a closeout visit are discussed along with a call for studies to provide clearer definitions of lost to follow-up and censoring times used in life-table analyses, especially when the primary event includes both fatal and nonfatal events. Control Clin Trials 2001;22:56-61

Effect of calcium supplementation on serum cholesterol and blood pressure. A randomized, double-blind, placebo-controlled, clinical trial

OBJECTIVE

To test the effect of daily supplemental calcium on serum total and high-density lipoprotein cholesterol (HDL-C) levels and blood pressure in adults.

DESIGN

Randomized, double-blind, placebo-controlled clinical trial; adjunct study to a trial of calcium and colon cell proliferation in patients with sporadic adenoma.

SETTING

Outpatient clinic.

PATIENTS

A total of 193 men and women, aged 30 to 74 years.

INTERVENTION

Treatment with 1.0 and 2.0 g/d of elemental calcium vs placebo over a 4-month period for cholesterol determinations and 6 months for blood pressure.

MAIN OUTCOME MEASURES

Serum total cholesterol and HDL-C levels, systolic and diastolic blood pressure.

RESULTS

Because there were no apparent differences in responses between the 1.0-g and 2.0-g calcium groups, their data were combined and compared with those of the placebo group. Among all participants, the mean total cholesterol level dropped 0.07 mmol/L (2.9 mg/dL) (1.3%) (P = .43) more, and the mean HDL-C level dropped 0.01 mmol/L (0.4 mg/dL) (1.1%) (P = .71) less in the calcium group than in the placebo group. Among participants without a history of hypercholesterolemia, the mean total cholesterol level dropped 0.18 mmol/L (6.8 mg/dL) (3.3%) (P = .10) and the HDL-C level dropped 0.02 mmol/L (0.6 mg/dL) (1.5%) (P = .61) more in the calcium group than in the placebo group. Among all participants, there was no apparent change in blood pressure until 6 months, when the mean systolic blood pressure dropped 0.8 mm Hg (0.6%) (P = .85) and the mean diastolic blood pressure dropped 0.4 mm Hg (0.5%) (P = .80) more in the calcium group than in the placebo group.

CONCLUSIONS

There were no substantial or statistically significant effects of calcium supplementation on total cholesterol or HDL-C levels or on blood pressure. There was a suggestion (not statistically significant) of a 0.07 to 0.18 mmol/L (3-7 mg/dL) or 2% to 4% drop in the total cholesterol level, a finding similar to that reported in other studies, which indicates the need for further study.

Urinary isoflavonoid and lignan excretion on a Western diet: relation to soy, vegetable, and fruit intake

Dietary isoflavone and lignan phytoestrogens are potential chemopreventive agents. This has led to a need to monitor exposure to these compounds in human populations and to determine which components of a mixed diet contribute to the exposure. Typically, urinary isoflavonoid excretion is associated with soy consumption and that of lignans is associated with whole grains. However, other plant foods are known to contain phytoestrogen precursors. The purpose of this study was to examine the association between urinary isoflavonoid and lignan excretion and intakes of vegetables and fruits (V&F). Isoflavonoids (genistein, daidzein, O-desmethylangolensin, and equol) and lignans (enterolactone, enterodiol, and matairesinol) were measured in urine collected for 3 days from 49 male and 49 female volunteers (age, 18-37 years) reporting a wide range of habitual V&F intakes. Dietary intakes were assessed using 5-day diet records and a food frequency questionnaire. V&F groupings (total V&F, total V, total F, soyfoods, and V&F grouped by botanical families) were used to assess the relationship between V&F intake and urinary isoflavonoid and lignan excretion. Pearson correlations were performed. Intake of soyfoods was correlated significantly with urinary genistein (r = 0.40; P = 0.0001), O-desmethylangolensin (r = 0.37; P = 0.0002), daidzein (r = 034; P = 0.0007), and the sum of isoflavonoids (r = 0.39; P = 0.0001). There was no association between equol excretion and soy intake or between the isoflavonoids and any other V&F groupings. In addition, isoflavonoid excretion was correlated positively with intake of high-fat and processed meats, particularly among men who did not consume soy. This suggests that, even in the United States, on a Western diet, soyfoods are the primary contributors to isoflavone intake; however, additional "hidden sources" of soy may also contribute to exposure. In contrast, a variety of fiber-containing foods contributed to lignan excretion; the sum of the urinary lignans, enterodiol, enterolactone, and matairesinol, was associated with intake of total F (r = 0.27; P = 0.008), total V&F (r = 0.25; P = 0.01), soyfoods (r = 0.28; P = 0.006), and dietary fiber (r = 0.36; P = 0.0003). Overall, urinary phytoestrogens (isoflavonoids + lignans) were significantly higher in "high" compared with "low" V&F consumers. Compared with the "low" V&F group, the "high" group consumed diets that were, on average, higher in fiber and carbohydrate and soyfoods and lower in fat; thus, the urinary phytoestrogens may also be a useful marker of healthier dietary patterns.

Urinary sodium and potassium profile of blacks and whites in relation to education in two different geographic urban areas. TOMHS Research Group. Treatment of Mild Hypertension Study

The high Na/low K environment of modern society is related to the genesis of hypertension and stroke. There is prior evidence of racial, geographical, and social class differences in Na and K intake and blood pressure. Baseline data from the Treatment of Mild Hypertension Study (TOMHS) was used to assess urinary Na and K excretion profiles by race, clinic geographic area, and education. Participants were adult black and white hypertensive patients from the Birmingham, Alabama, and Chicago, Illinois, area. Level of education was categorized as: less than college graduate and college graduate or more. Two overnight urine samples were collected and analyzed for Na and K at entry from 154 blacks and 281 whites. The urinary Na:K ratio was significantly higher in both blacks (5.1 v 3.8, P < .001) and whites (4.1 v 3.4, P < .005) in Birmingham compared with Chicago. This was primarily due to the lower excretion of urinary K in blacks (12.8 v 16.9 mmol/8 h, P < .01) and whites (14.0 v 16.5 mmol/8 h, P < .01). The highest urinary Na:K ratio was observed in blacks in Birmingham with lower education level; urinary Na excretion was high in blacks with a lower education level in both cities. No such differences were seen in whites. Although TOMHS was not population-based, these findings suggest the possibility that potassium intake among persons with stage 1 hypertension is related to geographic area in both blacks and whites, and sodium intake is inversely related to education level in blacks.

Colorectal epithelial cell proliferative kinetics and risk factors for colon cancer in sporadic adenoma patients

Colorectal epithelial cell proliferative kinetics are altered in patients at increased risk for colon cancer: proliferation rates [labeling index (LI)] are higher and there is a shift of the proliferative zone from one confined to the lower 60% of the colonic crypt to one that includes the entire crypt (higher phi(h)). To assess factors associated with LI and phi(h), we performed a cross-sectional analysis using baseline rectal mucosal biopsies from sporadic adenoma patients participating in a chemoprevention trial. Biopsies (taken without preparatory cleansing) were taken 10 cm above the level of the anus, and proliferation was assessed by detection of endogenous S-phase-associated proliferating cell nuclear antigen by immunohistochemical methods. High-quality, scorable biopsies were obtained for 115 patients, and using analysis of covariance and multiple linear regression, the LI and phi(h) were evaluated in relation to diet and other lifestyle factors, demographics, anthropometrics, family history of colon cancer, and polyp history. Statistically significant findings included the following: (a) The LI for those in the upper versus the lowest tertile of vegetable and fruit consumption was, proportionately, 35% lower (3.4% versus 5.3%; P < 0.001); for vitamin supplement users versus nonusers, it was 36% lower (3.3 versus 5.2%; P < 0.001); for recurrent versus incident polyp patients, it was 36% higher (6.2 versus 4.0%; P < 0.001); and for those with rectal polyps only versus those with colon polyps only, it was 28% higher (6.0 versus 4.3%; P = 0.05); and (b) the phi(h) for those in the upper versus the lowest tertile of sucrose consumption was, proportionately, 48% higher (7.1% versus 3.7%; P = 0.01). These results indicate that (a) colorectal epithelial cell proliferation rates are higher in recurrent adenoma patients than in incident adenoma patients and in patients with rectal adenomas only versus those with colon adenomas only, but they are lower in patients with higher intakes of vegetables and fruit and in those who take vitamin/mineral supplements, and (b) the distribution of proliferating cells is shifted toward more inclusion of the upper 40% of the crypt in patients with higher intakes of sucrose. The pattern of positive, negative, and null associations of potential risk factors with cell proliferation is similar to that commonly found with colonic neoplasms.

Higher education and income are related to a better Na:K ratio in blacks: baseline results of the Treatment of Mild Hypertension Study (TOMHS) data

In the United States, blacks have higher rates of hypertension than whites. A possible contributing factor to this higher rate of hypertension could be dietary differences between blacks and whites relating to sodium and potassium intake, which in turn could be related to socioeconomic differences between blacks and whites. Baseline data from the Treatment of Mild Hypertension Study (TOMHS) was used to assess differences in the urinary excretion of sodium and potassium, and the Na:K ratio between black and white participants, and also to explore the relationship of socioeconomic status (SES) and urinary electrolyte excretion within each ethnic group. Participants were men and women ages 45 to 69 with stage I diastolic hypertension (DBP < or = 99 mm Hg). Level of education and annual household income were used as indicators of SES. Two overnight urine samples were collected and analyzed for Na and K at entry on 172 black and 710 white participants. Blacks had a significantly higher mean Na:K ratio than whites, 4.3 v 3.6 (P < .001). This was primarily due to higher urinary Na excretion in blacks than whites, 57.8 v 52.7 mmol/8 h (P = .05). Analysis by education and income level showed that higher levels of urinary Na and Na:K in blacks than whites was restricted to those with lower education and income levels. For higher education and income levels, blacks had slightly lower levels of urinary Na and Na:K than whites. Correspondingly, education and income levels were related to urinary Na and Na:K in blacks but not in whites. This suggests that lower SES blacks could benefit from interventions to reduce dietary Na and increase dietary K, which would decrease their urinary Na:K ratio and may make them less prone to developing hypertension.

Relationships of quality-of-life measures to long-term lifestyle and drug treatment in the Treatment of Mild Hypertension Study

OBJECTIVES

To compare 5 antihypertensive drugs and placebo for changes in quality of life (QL). To assess the relationship of lifestyle factors and change in lifestyle factors to QL in participants with stage I diastolic hypertension.

METHODS

The Treatment of Mild Hypertension Study (TOMHS) was a randomized, double-blind, placebo-controlled clinical trial with minimum participant follow-up of 4 years. It was conducted at 4 hypertension screening and treatment academic centers in the United States. The cohort consisted of 902 men and women with hypertension, aged 45 to 69 years, with diastolic blood pressures less than 100 mm Hg. Informed consent was obtained from each participant after the nature of the procedures had been fully explained. Sustained nutritional-hygienic intervention was administered to all participants to reduce weight, to reduce dietary sodium and alcohol intake, and to increase physical activity. Participants were randomized to take (1) acebutolol (n = 132); (2) amlodipine maleate (n = 131); (3) chlorthalidone (n = 126); (4) doxazosin mesylate (n = 134); (5) enalapril maleate (n = 135); or placebo (n = 234). Changes in 7 QL indexes were assessed based on a 35-item questionnaire: (1) general health; (2) energy or fatigue; (3) mental health; (4) general functioning; (5) satisfaction with physical abilities; (6) social functioning; and (7) social contacts.

RESULTS

At baseline, higher QL was associated with older age, more physical activity, lower obesity level, male gender, non-African American race, and higher educational level. Improvements in QL were observed in all randomized groups, including the placebo group during follow-up; greater improvements were observed in the acebutolol and chlorthalidone groups and were evident throughout follow-up. The amount of weight loss, increase in physical activity, and level of attained blood pressure control during follow-up were related to greater improvements in QL.

CONCLUSIONS

In patients with stage I hypertension, antihypertensive treatment with any of 5 agents used in TOMHS does not impair QL. The diuretic chlorthali-done and the cardioselective beta-blocker acebutolol appear to improve QL the most. Success with lifestyle changes affecting weight loss and increase in physical activity relate to greater improvements in QL and show that these interventions, in addition to contributing to blood pressure control, have positive effects on the general well-being of the individual.

Relation of dietary fiber to blood lipids in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter addresses relations between intake of fiber--total, soluble, and insoluble--and blood lipids in the Multiple Risk Factor Intervention Trial through use of baseline data (single measurement), averages of four to five 24-h recalls and blood lipid determinations collected during annual follow-up examinations, and change from baseline to follow-up. No significant associations were observed at baseline. Consistent highly significant inverse associations were seen in analyses of follow-up measurements. Results from change data were of intermediate strength and consistency. These variations were in all likelihood due to the low reliability of a single 24-h recall at baseline for determination of dietary intake and change in intake for individuals. From follow-up data, plasma total and low-density-lipoprotein (LDL) cholesterol concentrations were lower by approximately 5 mg/dL for men in the special intervention group in quintile 5 of total fiber intake (25 g/d) compared with men in quintile 1 (8 g/d), after adjustment for average body mass index and intake of alcohol, saturated and polyunsaturated fatty acids, and dietary cholesterol. Results were similar for men in the usual care group. There were no adverse effects on high-density-lipoprotein cholesterol, nor any consistent associations with plasma triglycerides. Thus, increasing dietary fiber can provide additional reduction in blood total and LDL cholesterol and consequent improvement in the lipid profile, over and above the beneficial effects of a fat-modified diet.

Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of Mild Hypertension Study (TOMHS)

Problems with sexual function have been a long-standing concern in the treatment of hypertension and may influence the choice of treatment regimens and decisions to discontinue drugs. The Treatment of Mild Hypertension Study (TOMHS) provides an excellent opportunity for examination of sexual function and effects of treatment on sexual function in men and women with stage I diastolic hypertension because of the number of drug classes studied, the double-blind study design, and the long-term follow-up. TOMHS was a double-blind, randomized controlled trial of 902 hypertensive individuals (557 men, 345 women), aged 45 to 69 years, treated with placebo or one of five active drugs (acebutolol, amlodipine maleate, chlorthalidone, doxazosin maleate, or enalapril maleate). All participants received intensive lifestyle counseling regarding weight loss, dietary sodium reduction, alcohol reduction (for current drinkers), and increased physical activity. Sexual function was ascertained by physician interviews at baseline and annually during follow-up. At baseline, 14.4% of men and 4.9% of women reported a problems with sexual function. In men, 12.2% had problems obtaining and/or maintaining an erection; 2.0% of women reported a problem having an orgasm. Erection problems in men at baseline were positively related to age, systolic pressure, and previous antihypertensive drug use. The incidences of erection dysfunction during follow-up in men were 9.5% and 14.7% through 24 and 48 months, respectively, and were related to type of antihypertensive therapy. Participants randomized to chlorthalidone reported a significantly higher incidence of erection problems through 24 months than participants randomized to placebo (17.1% versus 8.1%, P = .025). Incidence rates through 48 months were more similar among treatment groups than at 24 months, with nonsignificant differences between the chlorthalidone and placebo groups. Incidence was lowest in the doxazosin group but was not significantly different from the placebo group. Incidence for acebutolol, amlodipine, and enalapril groups was similar to that in the placebo group. In many cases, erection dysfunction did not require withdrawal of medication. Disappearance of erection problems among men with problems at baseline was common in all groups but greatest in the doxazosin group. Incidence of reported sexual problems in women was low in all treatment groups. In conclusion, long-term incidence of erection problems in treated hypertensive men is relatively low but is higher with chlorthalidone treatment. Effects of erection dysfunction with chlorthalidone appear relatively early and are often tolerable, and new occurrences after 2 years are unlikely. The rate of reported sexual problems in hypertensive women is low and does not appear to differ by type of drug. Similar incidence rates of erection dysfunction in placebo and most active drug groups caution against routine attribution of erection problems to antihypertensive medication.

Relation of changes in dietary lipids and weight, trial years 1-6, to changes in blood lipids in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

For men in the special intervention (SI) group of the Multiple Risk Factor Intervention Trial, the average decrease in serum total cholesterol was 16.9 mg/dL (6.7%); for men in the usual care (UC) group, the average decrease was 9.7 mg/dL (3.8%). The difference between the two groups for plasma total cholesterol was 6.2 mg/dL. Plasma low-density-lipoprotein (LDL) cholesterol decreased 10.6 mg/dL (6.6%) in SI men and 5.4 mg/dL (3.4%) in UC men. Mean weight losses were 3.0 lb (1.36 kg) and 0.1 lb (0.05 kg) for SI and UC men, respectively. Change in blood total cholesterol was directly related to baseline concentration; for men with serum total cholesterol > or = 220 mg/dL, those in the SI group decreased their total cholesterol by 7.8% (design goal: 10%) and those in the UC group by 4.8% (expected: 0%). Change in dietary lipid intake (summarized by the Keys score) for SI men was significantly related to changes in blood total cholesterol, LDL cholesterol, and triglyceride, but not to change in high-density-lipoprotein (HDL) cholesterol. Controlled for weight change, coefficients for Keys score change were smaller but remained significantly related to each blood lipid except HDL cholesterol. Weight loss was associated with favorable effects on all blood lipids. Influences of change in diet and weight on blood lipids were quantitatively less for hypertensive men for serum total cholesterol, HDL cholesterol, and triglyceride than for nonhypertensive men. Nonsmokers had greater decreases than smokers in blood total cholesterol, LDL cholesterol, and triglyceride.

Relation of body mass and alcohol, nutrient, fiber, and caffeine intakes to blood pressure in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter presents analyses of relations of dietary variables to blood pressure, systolic (SBP) and diastolic (DBP), for men in the special intervention (SI) and usual care (UC) groups in the Multiple Risk Factor Intervention Trial. For each dietary factor, analyses were done at baseline, for trial years 1-6, and for change from baseline to years 1-6. Analyses were done for all participants and for men receiving or not receiving antihypertensive drug treatment and were controlled for age, race, education, serum cholesterol, smoking, special diet status, and (for specific nutrients) body mass index and alcohol intake. Nutrient data for trial years 1-6, which are based on four or five dietary recalls per man, are more reliable than the baseline or change data, which are based on only one recall. Therefore, this summary focuses on data for trial years 1-6, for SI and UC men pooled. Regression analyses confirmed direct independent relations of body mass index, alcohol intake, sodium, and ratio of sodium to potassium to SBP and DBP, and an inverse relation of potassium to SBP and DBP. Dietary starch was directly related to SBP and DBP; dietary saturated fatty acid and cholesterol and Keys score were directly related to DBP; dietary magnesium, fiber, and caffeine were inversely related to SBP and DBP; and dietary protein, polyunsaturated fatty acids, the ratio of polyunsaturated to saturated fatty acid, and other simple carbohydrates were inversely related to DBP. Method problems, all tending to produce underestimations, are also reviewed.

Relation of dietary carbohydrates to blood lipids in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter explores relations between reported intake of dietary carbohydrates and measurements of plasma lipids at baseline and during trial years 1-6 of the Multiple Risk Factor Intervention Trial. With control for dietary lipids, alcohol, and other factors, total carbohydrate intake at baseline was inversely related to baseline plasma total cholesterol and high-density-lipoprotein (HDL) cholesterol; starch and other simple carbohydrates were unrelated to plasma lipids and sucrose was inversely related to HDL cholesterol. During trial years 1-6, men assigned to the special intervention group increased their intake of starch and other simple carbohydrates as they decreased their fat intake, and lowered their intakes of refined and processed sucrose. Total carbohydrate intake of these men was inversely related to total, low-density-lipoprotein (LDL), and HDL cholesterol. Starch and sucrose intakes were also inversely related to HDL cholesterol. In contrast, intake of other simple carbohydrates was directly related to HDL, and inversely related to plasma total and LDL cholesterol. For men in the highest quintile of intake of other simple carbohydrates compared with men in the lowest quintile, plasma total cholesterol was lower by 3.6 mg/dL, LDL cholesterol was lower by 4.3 mg/dL, and HDL cholesterol was higher by 1.6 mg/dL. Findings were generally similar for men in the usual care group.

Relation of smoking at baseline and during trial years 1-6 to food and nutrient intakes and weight in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter describes dietary composition according to cigarette smoking status at baseline and changes in smoking status during follow-up for men in the special intervention (SI) and usual care (UC) groups of the Multiple Risk Factor Intervention Trial. Five patterns of smoking behavior were defined: 1) sustained nonsmoking, 2) early (years 1-2 of the trial) sustained quitting, 3) late (years 3-6 of the trial) sustained quitting, 4) recidivism, and 5) continued smoking. SI men who quit smoking showed greater favorable changes in dietary lipid composition and micronutrient intake than did continued smokers, and these changes were in many instances as great as favorable changes made by nonsmokers. On the other hand, SI men who quit smoking gained an average of 3.8 lb (1.7 kg), in contrast with nonsmokers who lost an average of 6.4 lb (2.9 kg). The gain by SI quitters was, however, less than that by UC quitters, who gained 6.5 lb (3.0 kg). Moreover, despite weight gain, net change in high-density-lipoprotein (HDL) cholesterol for SI quitters was positive. With the associated decrease in low-density-lipoprotein (LDL) cholesterol, early SI quitters had the most improvement in ratio of LDL to HDL among all subgroups. Thus, unfavorable nutritional patterns of smokers put them at double jeopardy regarding cardiovascular and other chronic diseases; additionally, long-term risks can be improved not only by smoking cessation but also by achievement of healthier eating patterns.

Nutritional adequacy of diets reported at baseline and during trial years 1-6 by the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter addresses whether a fat-modified diet as implemented by special intervention participants in the Multiple Risk Factor Intervention Trial affected intake of vitamins and minerals, and whether nutritional adequacy was altered by this dietary intervention. Despite likely underreporting of intake, for men in the special intervention group, most mean intakes of 15 micronutrients estimated from 24-h recalls were above established recommended dietary allowances. A few means were slightly below; lowest was zinc at 77% (from 98% at baseline) followed by calcium at 79% (from 102% at baseline). Calculated as nutrient densities (per 1000 kcal), nutrients that were below indexes of nutritional quality (the corresponding standard based on nutrient density) during follow-up, although not reduced below baseline by this measure, were vitamin D, calcium, iron (marginally), and zinc. Analyses by food groups indicated that intake of these nutrients might have been improved by greater replacement of high- and medium-fat dairy products with low-fat dairy products (for vitamin D and calcium) and of high-fat meats with low-fat meats, fish, or poultry (for iron and zinc), or (because iron was adequate) by increasing consumption of vegetables and whole-grain products. The safety of the eating pattern was further confirmed by more favorable micronutrient profiles in men who adhered best to the intervention program, as measured by degree of serum cholesterol reduction and weight loss.

Food group and macronutrient intakes, trial years 1-6, in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial

This chapter presents changes in dietary intake reported by men in the special intervention (SI) and usual care (UC) groups from baseline through 6 y of follow-up in the Multiple Risk Factor Intervention Trial. Changes in nutrients by SI men after 1 y of following the intensive intervention program were as follows: reduced intake of total fat (from 38.4% to 34.3% of energy), saturated fatty acids (14.2% to 10.4% of energy), and cholesterol (448 to 263 mg/d), and increased intake of polyunsaturated fatty acids (from 6.4% to 8.6% of energy). These changes were maintained and did not increase through the remaining 5 y. UC men reported small changes in similar directions. Most of the change in saturated fatty acid intake by SI participants was from high-fat meat and high- and medium-fat dairy products. Reduction in dietary cholesterol was achieved primarily by substantial decreases in intake of eggs and high-fat meats. Several baseline factors were associated with amount of dietary change in SI men. Greater changes were seen in men with higher baseline serum cholesterol concentrations, in those not consuming a special diet, in nonsmokers followed by lighter smokers, in hypertensive than in non-hypertensive men, in older participants, in white than in black men, in moderate drinkers than in nondrinkers or those consuming > or = 22 drinks/wk, and in those with no "stressful life events" than in those reporting one or more life events.

Adherence to dietary recommendations in the special intervention group in the Multiple Risk Factor Intervention Trial

This chapter presents findings on adherence to the Multiple Risk Factor Intervention Trial eating pattern by special intervention participants, on the basis of measures other than the 24-h dietary recall and blood cholesterol concentrations. These additional assessments included subjective ratings by a nutritionist, used during follow-up years 1 and 2, and a food record rating that was calculated from a 3-d food record, used during years 3-6. An additional tool used during the latter part of the trial was a checklist for evaluating degree of shortfall of the participant's diet from recommendations, level of motivation toward adherence, and factors in the social environment potentially influencing dietary behavior. Subjective ratings and food record ratings indicated that approximately 40-65% of participants were good or excellent adherers, with declines in these percentages over time. There were consistent strong relations between these ratings and change in serum cholesterol. Checklist evaluations gave similar overall findings, with about one-half to three-quarters of participants rated positively on infrequency of deviation from the eating pattern, motivation, and conducive environment. Several baseline traits predicted adherence. Adherence was better in older participants, in white than in black men, in nondrinkers, in those with fewer stressful life events, in those eating away from home less often, in less overweight men (although heavier participants exhibited greater changes in serum cholesterol, perhaps reflecting their poorer baseline diets), in those with higher serum cholesterol and diastolic blood pressure, and in nonsmokers.

Method issues in dietary data analyses in the Multiple Risk Factor Intervention Trial

The selection process in the Multiple Risk Factor Intervention Trial caused relations between risk factors to differ between participants who were randomly assigned into the study and the screening population. Cigarette smoking, blood pressure, and serum cholesterol were moderately inversely related to each other in the randomly assigned population whereas these relations in the unselected population were direct and small in magnitude. This problem was addressed by covariate adjustment in analyses. The selection process also created an artificially high initial mean concentration of serum cholesterol; the mean plasma concentration at the second screening was 15 mg/dL lower than at the first screening. Most of this difference is attributable to regression to the mean. To account for this problem, emphasis was placed on change in plasma cholesterol over time, calculated from the second-screening measurement. Examination of the reliability of nutrition data based on one 24-h dietary recall showed that nutrient-biochemical relations are subject to considerable regression-dilution bias. The ratios of "within" to "between" components of variability were typically between one and four. Analyses in which multiple follow-up measures were averaged are emphasized in this monograph. Men assigned to the special intervention group reported considerable reductions in total energy intake, which was not consistent with observed weight loss. The most likely explanation for this is underreporting or underconsumption the day before the recall. To partially adjust for this, nutrient data are often expressed both in absolute units and as nutrient densities.

Food group and nutrient intakes at baseline in the Multiple Risk Factor Intervention Trial

This chapter relates food and nutrient intakes at baseline to other facets of reported dietary behavior, major risk factors, and sociodemographic characteristics of men in the Multiple Risk Factor Intervention Trial. Intakes of total fat (38.4% of energy), saturated fatty acids (14.2%), and dietary cholesterol (492 mg/d) were similar to amounts seen in the first and second National Health and Nutrition Examination Surveys in the 1970s and were generally lower than findings from studies in the 1960s. There were inverse relations between total serum cholesterol and intakes of total fat, saturated and monounsaturated fatty acids, and dietary cholesterol. These paradoxical associations were largely attributable to findings in the 21% of men who reported following a special diet, indicating that use of such a diet increases with severity of hypercholesterolemia. Fat intake was directly related to number of meals per week eaten away from home, and to cigarette smoking. Patterns of food and nutrient intake were similar for men stratified by baseline blood pressure and antihypertensive treatment. Intake of total energy and percentages from various dietary fats decreased with age, as did use of sucrose and caffeine. White men consumed more dairy products than did other ethnic groups, whereas black men consumed more eggs, sugars, and sweets. Asians had the highest intake of cereal foods. Those with more education ate less high-fat meat products, more fruit, and more polyunsaturated oils, but also more high-fat dairy products and less breads and cereals; they also drank more alcohol.

Relationship to blood pressure of combinations of dietary macronutrients. Findings of the Multiple Risk Factor Intervention Trial (MRFIT)

BACKGROUND

Elevated blood pressure remains a widespread major impediment to health. Obesity and specific dietary factors such as high salt and alcohol intake and low potassium intake adversely affect blood pressure. It is a reasonable hypothesis that additional dietary constituents, particularly macronutrients, may also influence blood pressure.

METHODS AND RESULTS

Participants were 11,342 middle-aged men from the Multiple Risk Factor Intervention Trial (MRFIT). Data from repeat 24-hour dietary recalls (four to five per person) and blood pressure measurements at six annual visits were used to assess relationships, singly and in combination, of dietary macronutrients to blood pressure, adjusted for multiple possible confounders (demographic, dietary, and biomedical). Multiple linear regression was used to assess diet-blood pressure relations in two MRFIT treatment groups (special intervention and usual care), with adjustment for confounders, pooling of coefficients from the two groups (weighted by inverse of variance), and correction of coefficients for regression-dilution bias. In multivariate regression models, dietary cholesterol (milligrams per 1000 kilocalories), saturated fatty acids (percent of kilocalories), and starch (percent of kilocalories) were positively related to blood pressure; protein and the ratio of dietary polyunsaturated to saturated fatty acids were inversely related to blood pressure. These macronutrient-blood pressure findings were obtained in analyses that controlled for body mass, dietary sodium and ratio of sodium to potassium, and alcohol intake, each positively related to blood pressure, and intake of potassium and caffeine, both inversely related to blood pressure.

CONCLUSIONS

These data support the concept that multiple dietary factors influence blood pressure; hence, broad improvements in nutrition can be important in preventing and controlling high-normal and high blood pressure.

Hormone replacement therapy is associated with lower risk of adenomatous polyps of the large bowel: the Minnesota Cancer Prevention Research Unit Case-Control Study

Evidence of a role for steroid hormones and reproduction in colon neoplasia remains tantalizing but unclear. Hormone replacement therapy (HRT) has been reported in a number of recent studies to be associated with a reduced risk of colon cancer. A case-control study was undertaken to establish whether HRT is associated with lower risk of adenomatous polyps. This case-control study was undertaken as a project of the Minnesota Cancer Prevention Research Unit. Cases (n = 219) were women, ages 30-74 years with colonoscopy-proven, pathology-confirmed, adenomatous polyps of colon and rectum recruited at Digestive Healthcare PA (Minneapolis, MN). Two control groups were selected: women without polyps at colonoscopy (n = 438) at Digestive Healthcare and age- and zip code-matched women selected from the general community (n = 247). Response rates were 68% among those colonoscoped and 65% among community controls. Parity, age at first live birth, and oral contraceptive use did not distinguish cases from either control group. Multivariate adjusted odds ratios and 95% confidence limits for use of HRT for less than 5 years (compared with never use) among postmenopausal women were 0.52 (0.32-0.85) versus colonoscopy-negative controls and 0.74 (0.44-1.26) versus community controls. For 5 years of use or greater, the corresponding figures were 0.39 (0.23-0.67) and 0.61 (0.34-1.07). These results were not materially different when stratified on body mass index, oophorectomy, hysterectomy, aspirin use, or family history. There is no marked increase in risk even 5 years after cessation of HRT use. HRT appears to lower risk of colorectal adenomatous polyps, suggesting that it acts quite early in the neoplastic process. Mechanisms remain unclear. Reduction of risk of colorectal neoplasia is an additional benefit of postmenopausal HRT.

Long-term effects on plasma lipids of diet and drugs to treat hypertension. Treatment of Mild Hypertension Study (TOMHS) Research Group

OBJECTIVE

- To compare long-term plasma lipid changes among 6 antihypertensive treatment interventions for stage I (mild) hypertension.

DESIGN

- Multicenter, randomized, double-blind, parallel-group clinical trial.

SETTING

- Four academic clinical research units in the United States.

PARTICIPANTS

- A total of 902 men and women, aged 45 to 69 years, with stage I diastolic hypertension (diastolic blood pressure <100 mm Hg), recruited from 11914 persons screened in their communities.

INTERVENTIONS

- Participants were randomized to 1 of 6 treatment groups: (1) placebo, (2) beta-blocker (acebutolol), (3) calcium antagonist (amlodipine), (4) diuretic (chlorthalidone), (5) alpha1-antagonist (doxazosin), and (6) angiotensin-converting enzyme inhibitor (enalapril). All groups received intensive lifestyle counseling to achieve weight loss, dietary sodium and alcohol reduction, and increased physical activity.

MAIN OUTCOME MEASURES

- Changes in plasma total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides from baseline to annual visits through 4 years.

RESULTS

- Mean changes in all plasma lipids were favorable in all groups. The degree of weight loss with fat-modified diet and exercise was significantly related to favorable lipid changes. Significant differences (P<.01) among groups for average changes during follow-up in each lipid were observed. Decreases in plasma total cholesterol and LDL cholesterol were greater with doxazosin and acebutolol (for plasma total cholesterol, 0.36 and 0.30 mmol/L [13.8 and 11.7 mg/dL], respectively), less with chlorthalidone and placebo (0.12 and 0.13 mmol/L [4.5 and 5.1 mg/dL], respectively). Decreases in triglycerides were greater with doxazosin and enalapril, least with acebutolol. Increases in HDL cholesterol were greater with enalapril and doxazosin, least with acebutolol. Significant relative increases in plasma total cholesterol with chlorthalidone compared with placebo at 12 months were no longer present at 24 months and beyond, when mean plasma total cholesterol for the chlorthalidone group fell below baseline. Analyses of participants continuing to receive chlorthalidone throughout the 4 years of follow-up indicated this was not due solely to an increasing percentage of participants changing or discontinuing use of medication during follow-up.

CONCLUSIONS

- Weight loss with a fat-modified diet plus increased exercise produces favorable long-term effects on blood pressure and all plasma lipid fractions of adults with stage I hypertension; blood pressure reduction is enhanced to a similar degree by addition of a drug from any one of 5 classes of antihypertensive medication. These drugs differ quantitatively in influencing the degree of long-term favorable effects on blood lipids obtained with nutritional-hygienic treatment.

Calcium and colorectal epithelial cell proliferation in sporadic adenoma patients: a randomized, double-blinded, placebo-controlled clinical trial

BACKGROUND

The kinetics of colorectal epithelial cell proliferation is altered in patients at increased risk for colon cancer. Calcium administration ameliorates such proliferative changes in rodents. Findings in preliminary clinical trials have suggested similar effects in humans.

PURPOSE

A randomized, double-blind, placebo-controlled, clinical trial was designed to determine whether calcium supplementation will reduce the colorectal epithelial cell proliferation rate and normalize the distribution of proliferating cells within colorectal crypts (i.e., shift the zone of proliferation from the entire crypt to the lower 60% of the crypt, which is thought to be the normal proliferative zone of the crypt) in patients with sporadic adenomas.

METHODS

Sporadic adenoma patients (n = 193) were treated with placebo (n = 66), 1.0 g calcium (n = 64), or 2.0 g calcium (n = 63) daily for 6 months. Rectal mucosa biopsy specimens were obtained at base line and at 1-, 2-, and 6-month follow-up. Cell proliferation was measured by detection of S-phase-associated proliferating cell nuclear antigen by immunohistochemical methods. The cell proliferation rate, called labeling index (LI), was calculated as the proportion of labeled cells in the crypts. The deviation of the proliferative zone from the normal location in the lower 60% of the crypt was calculated as the proportion of labeled cells in the upper 40% of the crypt, called distributional index (phi h). The effects of calcium treatment on the LI and phi h were expressed as relative effects--(calcium follow-up/calcium base line)/(placebo follow-up/placebo base line). Calculations and inference testing of the relative effects were accomplished using a repeated-measures mixed model on log-transformed LI and phi h values. All statistical tests were two-sided.

RESULTS

Scorable biopsy specimens were obtained on 170 patients at base line, 164 at 1 month, 161 at 2 months, and 163 at 6 months. The difference in the change in the LI between the combined calcium groups and the placebo group was insignificant, with a relative effect of calcium versus placebo of 0.97 (P = .87). However, for the phi h, the relative effect of calcium versus placebo was 0.50 (P = .05) in the combined calcium groups, 0.56 (P = .16) in the 1.0-g calcium group, and 0.44 (P = .05) in the 2.0-g calcium group.

CONCLUSIONS

Calcium supplementation normalizes the distribution of proliferating cells without affecting the proliferation rate in the colorectal mucosa of sporadic adenoma patients.

IMPLICATIONS

These results support further study of whether alterations in colon cell proliferative kinetics represent true intermediate steps in colon carcinogenesis that can be used to investigate the etiology and prevention of, and whether a higher calcium consumption can reduce the risk of, colon cancer.

Plasma carotenoids as biomarkers of vegetable intake: the University of Minnesota Cancer Prevention Research Unit Feeding Studies

High vegetable intake has been associated with a decreased risk for various human cancers in epidemiological studies. Carotenoids are plant compounds that may both possess chemopreventive activity and be useful biomarkers of vegetable and fruit intake. Nineteen men and women were randomized into a controlled cross-over feeding study to measure the effect of vegetable intake on plasma carotenoid concentrations. Participants consumed each of 4 experimental diets for 9 days. The control diet consisted of commonly consumed foods and was essentially carotenoid free. High vegetable diets (carotenoid, cruciferous, and soy) consisted of the control diet plus carrots and spinach (carotenoid), broccoli and cauliflower (cruciferous), and tofu and FriChik (soy). Plasma carotenoid concentrations were highest on the carotenoid and cruciferous diets. When compared to the control, mean plasma alpha-carotene, beta-carotene, and lutein concentrations were 5.2, 3.3 and 2.2 times higher on the carotenoid diet, respectively (P < 0.001). Mean plasma lutein concentrations were 2.1 times higher on the cruciferous versus the control diet (P < 0.001). There were no differences between diets in plasma beta-cryptoxanthin and lycopene concentrations. These data indicate that plasma alpha-carotene, beta-carotene, and lutein may be useful biomarkers of carotenoid-rich food intake and that lutein may act as an intake biomarker of commonly consumed vegetables in the Cruciferae family. These findings should prove useful in undertaking dietary intervention trials because they suggest the feasibility of monitoring intake of some plant foods and of distinguishing among plant food groups.

Comparison of five antihypertensive monotherapies and placebo for change in left ventricular mass in patients receiving nutritional-hygienic therapy in the Treatment of Mild Hypertension Study (TOMHS)

BACKGROUND

Increased left ventricular mass (LVM) by echocardiography is associated with increased risk of cardiovascular disease. Thus, it is of interest to compare the effects of both pharmacological and nonpharmacological approaches to the treatment of hypertension on reduction of LVM.

METHODS AND RESULTS

Changes in LV structure were assessed by M-mode echocardiograms in a double-blind, placebo-controlled clinical trial of 844 mild hypertensive participants randomized to nutritional-hygienic (NH) intervention plus placebo or NH plus one of five classes of antihypertensive agents: (1) diuretic (chlorthalidone), (2) beta-blocker (acebutolol), (3) alpha-antagonist (doxazosin mesylate), (4) calcium antagonist (amlodipine maleate), or (5) angiotensin-converting enzyme inhibitor (enalapril maleate). Echocardiograms were performed at baseline, at 3 months, and annually for 4 years. Changes in blood pressure averaged 16/12 mm Hg in the active treatment groups and 9/9 mm Hg in the NH only group. All groups showed significant decreases (10% to 15%) in LVM from baseline that appeared at 3 months and continued for 48 months. The chlorthalidone group experienced the greatest decrease at each follow-up visit (average decrease, 34 g), although the differences from other groups were modest (average decrease among 5 other groups, 24 to 27 g). Participants randomized to NH intervention only had mean changes in LVM similar to those in the participants randomized to NH intervention plus pharmacological treatment. The greatest difference between groups was seen at 12 months, with mean decreases ranging from 35 g (chlorthalidone group) to 17 g (acebutolol group) (P = .001 comparing all groups). Within-group analysis showed that changes in weight, urinary sodium excretion, and systolic BP were moderately correlated with changes in LVM, being statistically significant in most analyses.

CONCLUSIONS

NH intervention with emphasis on weight loss and reduction of dietary sodium is as effective as NH intervention plus pharmacological treatment in reducing echocardiographically determined LVM, despite a smaller decrease in blood pressure in the NH intervention only group. A possible exception is that the addition of diuretic (chlorthalidone) may have a modest additional effect on reducing LVM.

Urinary albumin and N-acetyl-beta-D-glucosaminidase excretions in mild hypertension

Renal effects of mild hypertension and therapy have not been established. Since urinary albumin and N-acetyl-beta-D-glucosaminidase excretions reflect renal effects of hypertension, they were related to blood pressure, other cardiovascular risk factors, cardiac target organ effects, and response to therapy in mild hypertension (diastolic blood pressure 85-99 mm Hg). Participants were from two clinics of the Treatment of Mild Hypertension Study (TOMHS), a multicenter randomized, double-blind, controlled trial. Participants received nutritional-hygienic therapy and one of five active drugs or placebo. Urinary albumin and N-acetyl-beta-D-glucosaminidase excretions were assessed prospectively using office "spot" collections from one clinic (n = 213) and retrospectively using overnight collections from the other clinic (n = 210). Relationships were determined between protein excretions and blood pressure, age, gender, race, blood glucose, cholesterol concentrations, and indices of body mass and left ventricular mass and function at baseline. Treatment effects were assessed after 3 to 12 months. Spot and overnight albumin excretions related positively to baseline systolic blood pressure by univariate analyses. Spot albumin excretion related positively to systolic blood pressure, age, creatinine clearance, and left ventricular function while overnight albumin excretion related positively to left ventricular mass and female gender by multiple regression analyses. Spot, but not overnight, albumin excretion declined significantly with active drug therapy. N-acetyl-beta-D-glucosaminidase excretion did not relate to blood pressure or decline with therapy. The combined results suggest albumin excretion correlates with blood pressure, decreases with antihypertensive drug therapy, and is associated with greater left ventricular function and mass, as well as glomerular filtration rate, even at mild levels of hypertension.

Echocardiography in multicenter clinical trials: experience from the Treatment of Mild Hypertension Study

Echocardiography is becoming commonplace in clinical trials relating to hypertension for assessing changes in left ventricular mass (LVM). Factors affecting variability need to be considered in the design and management of such studies. These include (1) standardization of recordings and readings, (2) quality of recordings, (3) choice of sonographer vs. cardiologist readers, and (4) reader and temporal variability in measurements. The Treatment of Mild Hypertension Study (TOMHS) provides data and experience concerning these issues. TOMHS was a randomized trial of 902 participants, men and women, conducted in four clinical centers comparing six treatments for mild hypertension. M-mode echocardiograms were recorded at baseline and follow-up by centrally trained sonographers for assessment of LVM. Initial study design specified that each tracing be read by two sonographers with a study cardiologist adjudicating major differences in measurements. Poor agreement between sonographer readings prompted a change in design requiring one of two study cardiologists to read all tracings, with the same cardiologist reading all serial studies for a participant. Common tracings were read to assess interreader variability. The percentage of unreadable tracings varied by center (0.4-14.2%) and increased over follow-up. Reader agreement between the two cardiologists for LVM was greater (r = 0.83) than between sonographers (r = 0.68) or between sonographers and cardiologists (r = 0.64). The agreement between sonographer and cardiologist readings varied by center (range of r = 0.54-0.81), the highest correlations being in the two centers with physician echocardiographers. The intraclass correlation across visits for LVM was 0.66, being similar for all visit pairs. The standard deviation of the difference between baseline and follow-up LVM was 46 g using cardiologist readings, 51 g for readings made by the same sonographer, and 68 g for readings made by different sonographers, a difference that is large enough to appreciably affect sample size and power for studies. High-quality echocardiographic data can be obtained in multicenter trials, but this requires the continued training of sonographers and readers and ongoing monitoring of quality of tracings and measurements.

Plasma carotenoids as biomarkers of vegetable and fruit intake

Higher intakes of vegetables and fruits are associated with a lower risk of certain human cancers. A biomarker of vegetable and fruit intake would be a valuable research tool. A cross-sectional study assessed the association between plasma carotenoid concentrations and intakes of vegetables and fruits. Plasma carotenoids (alpha-carotene, beta-carotene, lutein, beta-cryptoxanthin, and lycopene) were measured in 50 male and 49 female participants, aged 18-37 years, with a wide range of habitual vegetable and fruit intakes. Dietary intakes were assessed via a food frequency questionnaire. Intake of vegetables and fruits and high carotenoid foods were measured. The sum of the plasma carotenoids (excluding lycopene) was highly correlated with intake of total vegetables and fruits (r = 0.59). Of the individual plasma carotenoids, plasma alpha-carotene had the highest correlation with intakes of both total vegetables (r = 0.50) and total fruits (r = 0.58). Intakes of foods with high carotenoid contents were correlated with their corresponding plasma concentrations as follows: high beta-carotene foods (r = 0.41); high lutein foods (r = 0.46); and high lycopene foods (r = 0.11). Multiple regression analyses showed that intake of total vegetables and fruits was the most significant determinant of each plasma carotenoid except lycopene. The utility of combining the plasma carotenoids as biomarkers of vegetable and fruit intake was assessed by a stepwise regression of total vegetable and fruit intake on plasma carotenoids. Significant determinants of intake of total vegetables and fruits were alpha-carotene, beta-cryptoxanthin, lutein, and energy intake (R2 = 0.53).(ABSTRACT TRUNCATED AT 250 WORDS)

Statistical analysis of proliferative index data in clinical trials

Measurements of proliferative activity in colonic epithelial cells are being used as surrogate endpoints in clinical trials for colon cancer prevention. Proliferative index data exemplify an important type of clinical trial endpoint. The outcome variable is a proportion in which the denominator is an ancillary statistic and in which measurement error and technician judgement are important sources of variability. The paper proposes a statistical model for a repeated measures clinical trial with this type of endpoint, in the context of proliferative activity data. The model is a two-stage random effects linear model in the log scale. In addition to fixed effects covariates, it explicitly incorporates two major sources of variability: the number of epithelial cells counted and the reader effect. Although the resulting likelihood is complicated, one can fit an approximate likelihood with minimal loss of efficiency using standard packages. We apply the model to a pilot randomized clinical trial.

Insulin as a predictor of coronary heart disease: interaction with apolipoprotein E phenotype. A report from the Multiple Risk Factor Intervention Trial

The objective of this study was to examine whether fasting serum insulin is a predictor of coronary heart disease in high-risk US men, and whether any such predictive role explains the enhanced cardiovascular risk seen in subjects with the apolipoprotein (Apo) E 3/2 phenotype. This was a nested case-control study of participants in the Multiple Risk Factor Intervention Trial. Ninety-four subjects who died from coronary heart disease (post-trial follow-up) and 114 case patients with myocardial infarction (during trial) were compared to control subjects (n = 414) matched (1:2) by age, center, randomization date, and intervention group. Overall, fasting serum insulin at baseline was not associated with case-control status. (Means for cases versus controls: 16.8 and 16.6 microU/mL), although serum insulin showed significant correlations with low-density-lipoprotein cholesterol, triglycerides, and uric acid. When stratified by the three Apo E phenotypes, 3/2, 3/3, 3/4, a significant association of fasting insulin with case-control status was seen for Apo E 3/2 individuals (19.9 versus 14.5 microU/mL; P = 0.02) but not for those with the other two phenotypes. Though fasting insulin is not a risk factor overall in this high-risk male population, it appears to contribute to cardiovascular risk in those with the Apo E 3/2 phenotype but does not explain the increased risk seen in these subjects. This new finding, if confirmed, may throw further light on the role of insulin in atherosclerosis.

Treatment of Mild Hypertension Study. Final results. Treatment of Mild Hypertension Study Research Group

OBJECTIVE

To compare six antihypertensive interventions for the treatment of mild hypertension.

DESIGN

Randomized, double-blind, placebo-controlled clinical trial.

SETTING

Four hypertension screening and treatment centers in the United States.

PARTICIPANTS

Hypertensive men and women, aged 45 to 69 years, with diastolic blood pressure less than 100 mm Hg.

INTERVENTION

Sustained nutritional-hygienic advice to all participants to reduce weight, dietary sodium intake, and alcohol intake, and increase physical activity. Participants were randomly allocated to take (1) placebo (n = 234); (2) chlorthalidone (n = 136); (3) acebutolol (n = 132); (4) doxazosin mesylate (n = 134); (5) amlodipine maleate (n = 131); or (6) enalapril maleate (n = 135).

MAIN OUTCOME MEASURES

Blood pressure, quality of life, side effects, blood lipid levels and analysis of other serum components, echocardiographic and electrocardiographic changes, and incidence of cardiovascular events over an average of 4.4 years of follow-up.

RESULTS

Blood pressure reductions were sizable in all six groups, and were significantly greater for participants assigned to drug treatment than placebo (-15.9 vs -9.1 mm Hg for systolic blood pressure and -12.3 vs -8.6 mm Hg for diastolic blood pressure; P < .0001). After 4 years, 59% of participants assigned to placebo and 72% of participants given drug treatment continued on their initial medication as monotherapy. A smaller percentage of participants assigned to the drug-treatment groups died or experienced a major nonfatal cardiovascular event than those assigned to the placebo group (5.1% vs 7.3%; P = .21). After including other clinical events, the percentage of participants affected was 11.1% for those in the drug-treatment groups and 16.2% for those in the placebo group (P = .03). Incidence rates of most resting electrocardiographic abnormalities were lower and quality of life was improved more for those assigned to drug-treatment groups rather than the placebo group. Differences among the five drug treatments did not consistently favor one group in terms of regression of left ventricular mass, blood lipid levels, and other outcome measures.

CONCLUSIONS

As an initial regimen, drug treatment in combination with nutritional-hygienic intervention was more effective in preventing cardiovascular and other clinical events than was nutritional-hygienic treatment alone. Drug-treatment group differences were minimal. Pending results from large-scale clinical trials to evaluate drug treatments for their effect on cardiovascular clinical events, these findings support the recommendations of the new fifth Joint National Committee report regarding treatment choices for people with stage 1 ("mild") hypertension.

Relation of apolipoprotein E phenotype to myocardial infarction and mortality from coronary artery disease

The apolipoprotein E polymorphism is a genetic determinant of low-density lipoprotein (LDL) cholesterol. Its status as a risk factor for coronary artery disease (CAD), either through a causal relation with LDL cholesterol level or independently, is less clearly established. Data from the Multiple Risk Factor Intervention Trial were used to examine the influence of apolipoprotein E phenotype on risk of coronary events. Of the 12,866 randomized participants, 619 were studied in a nested case-control design. CAD deaths (93) and nonfatal myocardial infarctions (113) were matched to 412 controls. The allele frequencies of apolipoprotein E in the white subset (epsilon 2 = 0.06, epsilon 3 = 0.79, and epsilon 4 = 0.15) were very similar to other nonselected white American populations, and the relation of apolipoprotein E on total and LDL cholesterol was generally similar to that seen in other studies, with the epsilon 2 allele being associated with lower and the epsilon 4 allele with higher total and LDL cholesterol. Allele frequencies were not the same for patients and control subjects. The presence of epsilon 4 was associated with an increased risk of CAD that was most evident for fatal cases. There was no relation between changes in LDL cholesterol over time during the trial and apolipoprotein E phenotypes.

The relation between serum albumin levels and risk of coronary heart disease in the Multiple Risk Factor Intervention Trial

The relation between serum albumin levels and subsequent incidence of myocardial infarction and coronary heart disease deaths was evaluated using stored serum from the Multiple Risk Factor Intervention Trial (MRFIT). There were 91 coronary heart disease deaths, 113 myocardial infarction patients, and 405 controls matched to cases within 5 years of age, treatment group, and clinic site. There was a highly significant inverse relation between serum albumin level and risk of coronary heart disease. Individuals with a baseline level of serum albumin greater than or equal to 4.7 g/dl had an odds ratio of 0.45 as compared with individuals with a baseline level of serum albumin less than 4.4 g/dl. The relation persisted after adjusting for other cardiovascular risk factors (blood pressure, smoking, and serum cholesterol). The association was stronger for coronary heart disease deaths than for surviving myocardial infarction patients, and for cigarette smokers as compared with cigarette nonsmokers. The deaths studied occurred in the time period at least 6 years after the sera had been obtained and up to 10.5 years of follow-up, and the myocardial infarctions studied occurred within the first 6.5 years of follow-up. There was no consistent relation between time and death due to coronary heart disease or myocardial infarction and albumin levels. Albumin levels are related to the acute phase reaction. Lower albumin levels may be a marker of persistent injury to arteries and progression of atherosclerosis and thrombosis. The consistent relation between albumin and coronary heart disease risk requires further evaluation.

Risk factor changes after cessation of intervention in the Multiple Risk Factor Intervention Trial. The MRFIT Research Group

BACKGROUND

The degree of maintenance of risk factor changes observed in post-trial follow-up of participants in the Multiple Risk Factor Intervention Trial (MRFIT) provides insights into long-term determinants of preventive behaviors, as well as post-trial mortality differentials.

METHODS

Nine hundred eighty-nine former MRFIT participants at four clinical centers were invited to be reexamined 2-3.5 years after the end of this 6- to 8-year trial. Seventy percent came to the clinics for measurements of systolic and diastolic blood pressure, plasma lipids and lipoproteins, serum thiocyanate, and dietary food frequency. With the addition of phone interviews, 82% provided self-report data on cigarette smoking and use of antihypertensive drugs.

RESULTS

Comparison of Special Intervention (SI) and Usual Care (UC) groups showed that differences persisted for total (6.5 mg/dl, P = 0.02) and low-density lipoprotein cholesterol (5.4 mg/dl, P = 0.04), and for diastolic blood pressure (1.6 mm Hg, P = 0.02). Differences were not significant for systolic blood pressure (1.8 mm Hg, P = 0.12), cigarette smoking, and serum thiocyanate. The plasma cholesterol difference represented 70% of the value at the end of intervention, and food frequency profiles were consistent with maintenance of an SI - UC difference. Loss of the SI - UC difference in smoking was attributable to both UC cessation and SI recidivism. The blood pressure difference was not attributable to different proportions of SI and UC men on medications, but possibly to differences in diuretic doses, use of multiple drugs, and adherence. There was a persisting contrast in use of specific diuretics, with more frequent use of chlorthalidone and less of hydrochlorothiazide in the SI group.

CONCLUSION

These findings suggest that cholesterol-lowering dietary changes are self-sustaining, while smoking cessation is less so, and may require continued intervention. Finally, the SI - UC differences in use of specific diuretics remains one hypothesis for explaining a portion of post-trial mortality trends.

Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial

We tested the hypothesis that hostility is associated with increased relative risk (RR) for coronary death and nonfatal myocardial infarction among participants in the prospective Multiple Risk Factor Intervention Trial (MRFIT). Cases (N = 192) were compared with matched controls (N = 384) on a variety of behavioral characteristics associated with the Type A behavior pattern (TABP), including three different but interrelated components of hostility. Logistic regression analyses revealed that only two of the eight TABP attributes analyzed on the overall sample were significant. Only total Potential for Hostility, when dichotomized into "low" and "high" categories, and the antagonistic interpersonal component of hostility (Stylistic Hostility) had positive unadjusted associations with coronary heart disease (CHD) incidence (RR = 1.7, p = 0.003; and RR = 1.5, p = 0.016, respectively). The global TABP and related paralinguistic attributes were not significantly related to CHD incidence. After adjustment for the traditional risk factors of age, serum cholesterol, blood pressure, and cigarette smoking, only dichotomous Potential for Hostility showed a significant relative risk (RR = 1.5, p = 0.032). Ordinal logistic regression revealed a nonsignificant effect.(ABSTRACT TRUNCATED AT 250 WORDS)