Arterial stiffness and kidney disease progression in the systolic blood pressure intervention trial

AIMS

Arterial stiffness increases with both advancing age and chronic kidney disease (CKD) and may contribute to kidney function decline, but evidence is inconsistent. We hypothesized that greater baseline arterial stiffness (assessed as pulse pressure (PP) and carotid-femoral pulse-wave velocity CFPWV)) was independently associated with kidney disease progression over the follow-up period (3.8 years) in the Systolic Blood Pressure Intervention Trial (SPRINT).

MATERIALS AND METHODS

8,815 SPRINT participants were included in the analysis of PP. 592 adults who participated in a SPRINT ancillary study that measured CFPWV were included in subgroup analyses. Cox proportional hazards analysis was used to examine the association between PP and time to kidney disease progression endpoints: (A) incident estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 in non-CKD participants at baseline; (B) 50% decline in eGFR, initiation of dialysis, or transplant in those with baseline CKD. Mixed model analyses examined the association of baseline PP/CFPWV with follow-up eGFR.

RESULTS AND CONCLUSION

Mean ± SD age was 68 ± 10 years, baseline PP was 62 ± 14 mmHg, and CFPWV was 10.8 ± 2.7 m/s. In the fully adjusted model, PP ≥ median was associated with an increased hazard of kidney disease progression endpoints (HR: 1.93 (1.43 - 2.61)). The association remained significant in individuals without (2.05 (1.47 - 2.87)) but not with baseline CKD (1.28 (0.55 - 2.65)). In fully adjusted models, higher baseline PP associated with eGFR decline (p < 0.0001 (all, CKD, non-CKD)), but baseline CFPWV did not. Among older adults at high risk for cardiovascular events, baseline PP was associated with kidney disease progression.

History of Cardiovascular Disease, Intensive Lifestyle Intervention, and Cardiovascular Outcomes in the Look AHEAD Trial

OBJECTIVE

To examine the effects of an intensive lifestyle intervention (ILI) on cardiovascular disease (CVD), the Action for Health in Diabetes (Look AHEAD) trial randomized 5,145 participants with type 2 diabetes and overweight/obesity to a ILI or diabetes support and education. Although the primary outcome did not differ between the groups, there was suggestive evidence of heterogeneity for prespecified baseline CVD history subgroups (interaction P = 0.063). Event rates were higher in the ILI group among those with a CVD history (hazard ratio 1.13 [95% CI: 0.90-1.41]) and lower among those without CVD (hazard ratio 0.86 [95% CI: 0.72-1.02]).

METHODS

This study conducted post hoc analyses of the rates of the primary composite outcome and components, adjudicated cardiovascular death, nonfatal myocardial infarction (MI), stroke, and hospitalization for angina, as well as three secondary composite cardiovascular outcomes.

RESULTS

Interaction P values for the primary and two secondary composites were similar (0.060-0.064). Of components, the interaction was significant for nonfatal MI (P = 0.035). This interaction was not due to confounding by baseline variables, different intervention responses for weight loss and physical fitness, or hypoglycemic events. In those with a CVD history, statin use was high and similar by group. In those without a CVD history, low-density lipoprotein cholesterol levels were higher (P = 0.003) and statin use was lower (P ≤ 0.001) in the ILI group.

CONCLUSIONS

Intervention response heterogeneity was significant for nonfatal MI. Response heterogeneity may need consideration in a CVD-outcome trial design.

Serum Sodium and Pulse Pressure in SPRINT

BACKGROUND

High dietary sodium intake may induce a small, yet physiologically relevant rise in serum sodium concentration, which associates with increased systolic blood pressure. Cellular data suggest that this association is mediated by increased endothelial cell stiffness. We hypothesized that higher serum sodium levels were associated with greater arterial stiffness in participants in the Systolic Blood Pressure Intervention Trial (SPRINT).

METHODS

Multivariable linear regression was used to examine the association between baseline serum sodium level and (i) pulse pressure (PP; n = 8,813; a surrogate measure of arterial stiffness) and (ii) carotid-femoral pulse wave velocity (CFPWV; n = 591 in an ancillary study to SPRINT).

RESULTS

Baseline mean ± SD age was 68 ± 9 years and serum sodium level was 140 ± 2 mmol/L. In the PP analysis, higher serum sodium was associated with increased baseline PP in the fully adjusted model (tertile 3 [≥141 mmol] vs. tertile 2 [139-140 mmol]; β = 0.87, 95% CI = 0.32 to 1.43). Results were similar in those with and without chronic kidney disease. In the ancillary study, higher baseline serum sodium was not associated with increased baseline CFPWV in the fully adjusted model (β = 0.35, 95% CI = -0.14 to 0.84).

CONCLUSIONS

Among adults at high risk for cardiovascular events but free from diabetes, higher serum sodium was independently associated with baseline arterial stiffness in SPRINT, as measured by PP, but not by CFPWV. These results suggest that high serum sodium may be a marker of risk for increased PP, a surrogate index of arterial stiffness.

Focus on fathers: paternal depression in the perinatal period

Aims:

This report aims to present a concise overview and synthesis of current research findings regarding paternal depression in the perinatal period.

Methods:

A literature search was conducted, primarily via PubMed and PsychNET, for English-language research studies and meta-analyses using combinations of the terms ‘perinatal’, ‘pregnancy’, ‘postpartum’, ‘depression’ AND ‘fathers’ OR ‘paternal’. Peer-reviewed articles were considered, and a representative sample of literature, with an emphasis on recent publications from a broad range of populations was summarized for each of the following sub-sections: prevalence, risk factors, impact on the infant/child, and healthcare costs.

Results:

Reported prevalence has ranged from 2.3% to 8.4%, with a significant degree of heterogeneity in rates, due to differences in multiple aspects of the methodology (timing, instruments, etc.). Nevertheless, rates of maternal depression remain higher than paternal depression, and higher rates of one are associated with higher rates of the other. The primary risk factors for paternal depression are maternal depression and the father’s history of severe depression, or symptoms of depression or anxiety prenatally. Biological mechanisms may underlie paternal depression, with changes reported in testosterone, cortisol and prolactin levels during this period. Paternal depression has been related to children’s behavioral, emotional and social function at 36 months and psychiatric disorders at 7 years, adjusting for maternal depression. Healthcare costs may also be impacted by paternal postpartum depression, with higher father–child dyad costs found after controlling for potential confounders.

Conclusions:

Focusing on fathers’ emotional well-being in the perinatal period is important in itself, as well as for their wives and children. Programs recommending screening for maternal perinatal mood and anxiety disorders should include inquiry regarding the father’s emotional state, and if his distress is reported it should be clarified and followed-up by support and intervention as necessary.

The use of short message services (SMS) to provide medical updating to parents in the NICU

OBJECTIVE

Premature delivery and prolonged hospitalization of infants in the neonatal intensive care unit (NICU) are very stressful for parents. As technology has advanced, short message services (SMS) have been used increasingly in the medical disciplines. To date, the use of SMS for updating patients and families regarding medical information has not been reported. We implemented the SMS technique to daily update the parents regarding the health status of their preterm infant. The objective of this study was to evaluate the use of SMS technology and to assess its impact on the parents and the nursing staff.

STUDY DESIGN

Parents and nurses completed questionnaires at two time periods: pre-SMS implementation (pre-SMSi) and post-SMS implementation (post-SMSi). The parent questionnaires included statements about medical information delivery, communication and trust between parents and medical staff, parental anxiety and overall satisfaction. The nurse questionnaires included statements about the expected and actual impact on their workload.

RESULTS

Comparison of the parents' responses at the two time periods indicated that in the post-SMSi time period, they felt that the physician was more available when needed (P=0.002), they were more comfortable about approaching the physician (P=0.001) and more satisfied with the medical information provided by the staff (P=0.03). In the post-SMSi period, 78.1% of the nurses noted that the SMS communication is a convenient and user-friendly method.

CONCLUSIONS

SMS updating is an easy and user-friendly technology that enriches the modalities of information delivery to parents of hospitalized preterm infants. It is a complementary and useful tool for encouraging and improving personal communication between parents and medical staff and should be considered part of quality improvement in health care.

Coronary heart disease risk factors and outcomes in the twenty-first century: findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify "microsize infarcts," caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.

Effect of experimentally reduced distal sensation on postural response to hip abductor/ankle evertor muscle vibration

This study assessed whether postural responses induced by vibratory perturbations of the hip abductors and ankle evertors, were modified when distal tactile sensation was experimentally reduced through cooling. Sixteen healthy subjects were investigated pre and post cooling. Subjects stood with their eyes closed with a stance width of 4 cm. A 2s vibratory stimulus was applied to the left or right hip abductor or ankle evertor muscle. The order of the site and side of the stimulation was randomised. The postural response to hip abductor and ankle evertor vibration was recorded using 3D motion analysis (Codamotion, Leicestershire). Medio-lateral centre of pressure motion was simultaneously recorded during quiet standing via a force plate (Kistler, UK). Pre-cooling people responded to unilateral ankle vibration with an ipsilateral translation and tilt of the pelvis, and an ipsilateral tilt of the trunk. People responded to unilateral hip vibration with a contralateral translation and tilt of the pelvis, and an ipsilateral tilt of the trunk. Following an experimental reduction in distal tactile sensation there was a significant reduction in the amplitude of pelvic tilt in response to ankle vibration (F(6.2)=P<0.05) and a significant increase in amplitude of pelvic tilt in response to hip vibration (F(5.2)=P<0.05). This suggests that the sensitivity to artificial stimulation of hip proprioception increases with distal cooling, possibly indicating a change in the gain/weighting placed upon sensory information from the hips.

Cognitive effects of statin medications

The demonstrated benefits of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) for cardiovascular and cerebrovascular disease are well established in the medical literature, and this class of medications is among those most commonly prescribed in the USA. In 2012, the US Food and Drug Administration issued updated recommendations regarding statin medications, and the panel's comments regarding memory impairment fostered clinical confusion (in part because of the lay media's amplification). Cognitive data from several large epidemiological studies have not reliably demonstrated a robust association between incident cognitive impairment and statin use, with some studies reporting a protective effect, some reporting an increased risk and others finding no association. Although several interventional studies have evaluated statins as a possible adjunctive treatment for Alzheimer's disease, none have clearly demonstrated a benefit. A small number of case series have reported infrequent memory difficulties associated with statin use. In these series, the patients' cognitive symptoms resolved after statin discontinuation. The existing medical literature does not suggest that cognitive considerations should play a major role in medical decision making to prescribe statins for the large majority of patients. As with any medication prescribed for older adults, careful clinical monitoring for side effects should be exercised. If a patient is suspected of having idiosyncratic memory impairment associated with use of a statin medication, the drug can be discontinued. The patient should then be followed with careful clinical observation for 1-3 months for resolution of the cognitive symptoms.

Achievement of optimal medical therapy goals for U.S. adults with coronary artery disease: results from the REGARDS Study (REasons for Geographic And Racial Differences in Stroke)

OBJECTIVES

In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial.

BACKGROUND

In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures.

METHODS

The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m(2); and 7) exercise ≥4 days per week.

RESULTS

The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals.

CONCLUSIONS

There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD.

Swallow syncope: clinical presentation, diagnostic criteria, and therapeutic options

We recently encountered three patients with episodes of syncope associated with food ingestion. A 31-year-old woman had an episode of syncope in the hospital while drinking soda. Transient asystole was noted on the telemonitor, confirming the diagnosis of swallow syncope. The other two patients were 78- and 80 year old gentlemen, respectively, who presented with recurrent and transient episodes of dizziness during deglutition. Extensive work-up of syncope was negative in both cases and a diagnosis of swallow syncope was made by clinical criteria. These cases illustrate the challenging problem of swallow syncope. The diagnosis can be suspected on the basis of clinical presentation and confirmed with the demonstration of transient brady-arrhythmia during deglutition. Medical management includes avoiding trigger foods, use of anticholinergics, and/or placement of a permanent cardiac pacemaker.

Trends in the prevalence, awareness, treatment and control of high low density lipoprotein-cholesterol among United States adults from 1999-2000 through 2009-2010

Marked increases in the awareness, treatment, and control of high low-density lipoprotein (LDL) cholesterol occurred among United States (US) adults from 1988-1994 to 1999-2004. An update to the Third Adult Treatment Panel guidelines was published in 2004, and it is unknown if these improvements have continued since the publication of these revised treatment recommendations. The aim of this study was to determine trends in the awareness, treatment, and control of high LDL cholesterol among US adults from 1999-2000 to 2009-2010 using nationally representative samples of US adults aged ≥20 years from 6 consecutive National Health and Nutrition Examination Surveys (NHANES) in 1999-2000 (n = 1,659), 2001-2002 (n = 1,897), 2003-2004 (n = 1,698), 2005-2006 (n = 1,692), 2007-2008 (n = 2,044), and 2009-2010 (n = 2,318). LDL cholesterol was measured after an overnight fast, and high LDL cholesterol and controlled LDL cholesterol were defined using the 2004 updated Third Adult Treatment Panel guidelines. Awareness and treatment of high cholesterol were defined using self-report. Among US adults, the prevalence of high LDL cholesterol did not change from 1999-2000 (37.2%) to 2009-2010 (37.8%). Awareness of high LDL cholesterol increased from 48.9% in 1999-2000 to 62.8% in 2003-2004 but did not increase further through 2009-2010 (61.5%). Among those aware of having high LDL cholesterol, treatment increased from 41.3% in 1999-2000 to 72.6% in 2007-2008 and was 70.0% in 2009-2010. Among US adults receiving treatment for high LDL cholesterol, the percentage with controlled LDL cholesterol increased from 45.0% in 1999-2000 to 65.3% in 2005-2006 and had decreased slightly by 2009-2010 (63.6%). In conclusion, high LDL cholesterol remains common among US adults. Additional efforts are needed to prevent high LDL cholesterol and increase the awareness, treatment, and control of high LDL cholesterol among US adults.

Association of race and sex with risk of incident acute coronary heart disease events

CONTEXT

It is unknown whether long-standing disparities in incidence of coronary heart disease (CHD) among US blacks and whites persist.

OBJECTIVE

To examine incident CHD by black and white race and by sex.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 24,443 participants without CHD at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, who resided in the continental United States and were enrolled between 2003 and 2007 with follow-up through December 31, 2009.

MAIN OUTCOME MEASURE

Expert-adjudicated total (fatal and nonfatal) CHD, fatal CHD, and nonfatal CHD (definite or probable myocardial infarction [MI]; very small non-ST-elevation MI [NSTEMI] had peak troponin level <0.5 μg/L).

RESULTS

Over a mean (SD) of 4.2 (1.5) years of follow-up, 659 incident CHD events occurred (153 in black men, 138 in black women, 254 in white men, and 114 in white women). Among men, the age-standardized incidence rate per 1000 person-years for total CHD was 9.0 (95% CI, 7.5-10.8) for blacks vs 8.1 (95% CI, 6.9-9.4) for whites; fatal CHD: 4.0 (95% CI, 2.9-5.3) vs 1.9 (95% CI, 1.4-2.6), respectively; and nonfatal CHD: 4.9 (95% CI, 3.8-6.2) vs 6.2 (95% CI, 5.2-7.4). Among women, the age-standardized incidence rate per 1000 person-years for total CHD was 5.0 (95% CI, 4.2-6.1) for blacks vs 3.4 (95% CI, 2.8-4.2) for whites; fatal CHD: 2.0 (95% CI, 1.5-2.7) vs 1.0 (95% CI, 0.7-1.5), respectively; and nonfatal CHD: 2.8 (95% CI, 2.2-3.7) vs 2.2 (95% CI, 1.7-2.9). Age- and region-adjusted hazard ratios for fatal CHD among blacks vs whites was near 2.0 for both men and women and became statistically nonsignificant after multivariable adjustment. The multivariable-adjusted hazard ratio for incident nonfatal CHD for blacks vs whites was 0.68 (95% CI, 0.51-0.91) for men and 0.81 (95% CI, 0.58-1.15) for women. Of the 444 nonfatal CHD events, 139 participants (31.3%) had very small NSTEMIs.

CONCLUSIONS

The higher risk of fatal CHD among blacks compared with whites was associated with cardiovascular disease risk factor burden. These relationships may differ by sex.

Association between Endothelial Biomarkers and Arterial Elasticity in Young Adults - The CARDIA Study

BACKGROUND

Reduced arterial elasticity and endothelial dysfunction both may indicate early cardiovascular (CV) disease in young adults. Pulse waveform analysis estimates large (LAE) and small (SAE) artery elasticity noninvasively. We assessed the associations between LAE and SAE and markers of endothelial dysfunction and CV risk factors.

METHODS

The Coronary Artery Risk Development in Young Adults (CARDIA) assessed arterial elasticity and other characteristics cross-sectionally in 389 men and 381 women aged 27-42 years in 1995 (CARDIA year 10) and circulating levels of P-selectin and soluble intercellular adhesion molecule 1 (sICAM-1) in 2000. We adjusted for variables included in the estimation of arterial elasticity (year 10 height, body mass index, age, heart rate, and blood pressure) and other year 10 characteristics.

RESULTS

Mean adjusted SAE was 8.5 vs. 7.6 ml/mmHg x100 in those with urine albumin/creatinine ratio </=4 vs. microalbuminuria (ratio > 25; p(trend) =0.008). Mean LAE was 25.6 vs. 24.2 ml/mmHg x10 in the lowest vs. highest quintile of P-selectin (p(trend) =0.004). sICAM-1 was unrelated to either LAE or SAE. Plasma triglycerides were inversely related to LAE (p(trend) =0.029). Cigarette smokers had lower SAE than nonsmokers (p(trend) = 0.009).

CONCLUSION

In addition to smoking and triglycerides, biomarkers for endothelial dysfunction were associated with impaired LAE and SAE in young adults.

A clustering analysis of lipoprotein diameters in the metabolic syndrome

Background

The presence of smaller low-density lipoproteins (LDL) has been associated with atherosclerosis risk, and the insulin resistance (IR) underlying the metabolic syndrome (MetS). In addition, some research has supported the association of very low-, low- and high-density lipoprotein (VLDL HDL) particle diameters with components of the metabolic syndrome (MetS), although this has been the focus of less research. We aimed to explore the relationship of VLDL, LDL and HDL diameters to MetS and its features, and by clustering individuals by their diameters of VLDL, LDL and HDL particles, to capture information across all three fractions of lipoprotein into a unified phenotype.

Methods

We used nuclear magnetic resonance spectroscopy measurements on fasting plasma samples from a general population sample of 1,036 adults (mean ± SD, 48.8 ± 16.2 y of age). Using latent class analysis, the sample was grouped by the diameter of their fasting lipoproteins, and mixed effects models tested whether the distribution of MetS components varied across the groups.

Results

Eight discrete groups were identified. Two groups (N = 251) were enriched with individuals meeting criteria for the MetS, and were characterized by the smallest LDL/HDL diameters. One of those two groups, one was additionally distinguished by large VLDL, and had significantly higher blood pressure, fasting glucose, triglycerides, and waist circumference (WC; P < .001). However, large VLDL, in the absence of small LDL and HDL particles, did not associate with MetS features. These associations held after additionally controlling for VLDL, LDL and HDL particle concentrations.

Conclusions

While small LDL diameters remain associated with IR and the MetS, the occurrence of these in conjunction with a shift to overall larger VLDL diameter may identify those with the highest fasting glucose, TG and WC within the MetS. If replicated, the association of this phenotype with more severe IR-features indicated that it may contribute to identifying of those most at risk for incident type II diabetes and cardiometabolic disease.

Lipoprotein lipase S447X variant associated with VLDL, LDL and HDL diameter clustering in the MetS

Background

Previous analysis clustered 1,238 individuals from the general population Genetics of Lipid Lowering Drugs Network (GOLDN) study by the size of their fasting very low-density, low-density and high-density lipoproteins (VLDL, LDL, HDL) using latent class analysis. From two of the eight identified groups (N = 251), ~75% of individuals met Adult Treatment Panel III criteria for the metabolic syndrome (MetS). Both showed small LDL diameter (mean = 19.9 nm); however, group 1 (N = 200) had medium VLDL diameter (mean = 53.1 nm) while group 2 had very large VLDL diameter (mean = 65.74 nm). Group 2 additionally showed significantly more insulin resistance (IR), and accompanying higher waist circumference and fasting glucose and triglycerides (all P < .01). Since lipoprotein lipase hydrolyzes triglyceride in the VLDL-LDL cascade, we examined whether these two patterns of lipoprotein diameter were associated with differences across two lipoprotein lipase (LPL) gene variants: D9N (rs1801177) and S447X (rs328).

Findings

Mixed linear models that controlled for age, sex, center of data collection, and family pedigree revealed no differences between the two groups for the D9N polymorphism (P = .36). However, group 2 contained significantly more carriers (25%) of the 447X variant than group 1 (14%; P = .04).

Conclusions

This was the first study this kind to show an association between LPL and large VLDL particle size within the MetS, a pattern associated with higher IR. Future work should extend this to larger samples to confirm these findings, and examine the long term outcomes of those with this lipoprotein diameter pattern.

Additional antianginal and anti-ischemic efficacy of mibefradil in patients concomitantly treated with long-acting nitrates for chronic stable angina pectoris

BACKGROUND

Mibefradil, a newly approved antihypertensive and antianginal drug, is the first member of a new class of calcium antagonists (CAs), the tetralol derivatives, that selectively blocks T-type Ca2+ channels in contrast to classical CAs which, at therapeutic concentrations, block only L-type Ca2+ channels. Since patients with chronic stable angina pectoris typically may be treated with the combination of a long-acting nitrate and a CA, the additive efficacy and safety of mibefradil in combination with nitrate therapy needs to be determined.

HYPOTHESIS

This study was designed to assess the efficacy, tolerability, and safety of mibefradil when added to long-acting nitrate therapy in patients with chronic stable angina pectoris.

METHODS

Following a 1-week placebo run-in period, patients were randomized to receive either mibefradil 50 mg (n = 96) or placebo (n = 93) once daily in addition to their nitrate therapy. After 2 weeks of active treatment, patients receiving the mibefradil were force titrated to 150 mg once daily for an additional 2 weeks. Exercise tolerance tests (ETTs) were performed at the end of Weeks 2 and 4; patients also maintained an anginal diary during the 4-week treatment period.

RESULTS

After 2 weeks of treatment with 50 mg mibefradil (within the current recommended dose range), a statistically significant but modest increase in total exercise duration was observed (treatment effect 16.4 s, p = 0.04). Similarly, there was a significant increase in time to onset of ischemia (treatment effect 26 s, p = 0.008). The adverse event profile of the 50 mg dose was indistinguishable from placebo, indicating that this dose was extremely well tolerated. At Week 4, the mibefradil-treated patients were taking 150 mg, which is above the current recommended dose range. The increase in total exercise duration was larger for the mibefradil 150 mg group than for the placebo group. For the intent-to-treat population, this difference did not reach statistical significance, whereas in the standard population it did (treatment effect 21 s, p = 0.05). The other two ETT variables, time to onset of angina and time to onset of 1 mm ST-segment depression, demonstrated significantly greater effect with mibefradil 150 mg (treatment effects 40 s, p = 0.002, and 55 s, p < 0.001, respectively, for the intent-to-treat population). Mibefradil 150 mg was associated with more adverse events than placebo, specifically, dizziness, leg edema, and postural hypotension.

CONCLUSIONS

This study demonstrates that mibefradil 50 mg once daily in the setting of the background long-acting nitrate therapy produces additive antianginal and anti-ischemic effects and is extremely well tolerated.

Diagnostic criteria and adjudication process both determine published event-rates: the ACTION trial experience

OBJECTIVE

Few trials report event-adjudication procedures in detail. Using data from the ACTION (A Coronary disease Trial Investigating Outcome with Nifedipine GITS) study, we compared the impact on event-rates of an adjudication strategy based on systematic screening of all reported serious adverse events (SAEs) with a strategy based on investigator diagnoses. The final diagnosis was always made by a critical events committee (CEC) using standard criteria.

METHODS

ACTION randomized 7665 patients with stable angina to either nifedipine or placebo. Pre-specified events included acute or procedural myocardial infarction (MI), refractory angina, heart failure and debilitating stroke. Clinically related SAEs including in-hospital procedures were combined into episodes independent from the investigator diagnoses entered on SAE reports. All fatal episodes and those episodes suggestive of pre-specified events were adjudicated by the CEC.

RESULTS

During follow-up, 17,081 episodes were reported in 5312 patients. The SAE descriptions ruled out the occurrence of a pre-specified event in 28%. The remaining 72% were adjudicated by the CEC and 616 cases of MI, 361 of refractory angina, 275 of heart failure and 190 of debilitating stroke were diagnosed (total=1442). Had adjudication by the CEC been limited to the 3924 episodes (2397 patients) that were fatal or for which the investigator had reported any of the diagnoses mentioned, 98 cases of MI, 35 of refractory angina, 81 of heart failure and 14 of debilitating stroke would have been missed (total=228).

CONCLUSION

Both the diagnostic criteria used and the adjudication process determine event-rates and conclusions about treatment effects in clinical trials. Published trial reports should always state if event-adjudication was independent of the diagnoses of investigators, and if all events of interest were adjudicated or only the first one.

Children injured following TV tipovers in Israel, 1997-2003

BACKGROUND

According to the US Consumer Product Safety Commission, about 7000 children, many under age five, are treated annually at emergency rooms for injuries associated with unintentional tipping of television (TV) and furniture. However, the professional literature does not reflect much inquiry regarding this source of risk. In Israel, cases of children injured following TV tipover are reported in newspapers but no studies were conducted in Israel on this issue. The aim of this report is to present data regarding frequency and characteristics of children injured following a falling TV in Israel during recent years, in order to provide more specific information for advising policymakers and raising awareness about this growing danger.

METHODS

Data were obtained from the Israeli National Trauma Registry, and included injured children (0-17) hospitalized between 1997 and 2003, because of TV-related injury. Demographic information, Injury Severity Score (ISS), injured body region, surgical intervention, admission to the intensive care unit, length of hospital stay, destination at discharge and mortality were analysed.

RESULTS

There were 116 children injured following TV tipover during the years analysed, increasing from nine in 1997 to 27 in 2003. Over half of the children (54.3%) were aged 1-2 years; 57.8% were boys. Three-quarters of the TV-related injuries were head and neck injuries; nearly one-fifth had ISS scores of over 15. The mean was 4.3 (median = 2 days); 15 children (12.9%) required surgery and four children died in the hospital.

CONCLUSION

The findings reflect the fact that TV tipover is a growing source of danger that can be serious and should be brought to the attention of the public, health professionals and policymakers. Specific, age-related recommendations should be proposed, such as placing TVs on low and stable surface and not placing the remote controls on the top of the set.

[A Hebrew version of the FLACC scale: measurement of pain in non-verbal children]

BACKGROUND

The Israeli Ministry of Health requires that every patient have their pain routinely and systematically measured when there are treated in any of the country's medical institutions. Measurement guides treatment and enables follow-up of pain over time. Self-assessment of pain is the gold standard. Measurement is standardized by using scales representing intensity from "no pain" to "unbearable pain". Three-year-olds can assess their own pain, but younger children, or those who are non-verbal due to a medical procedure, cannot. Scales for this population rely on behavioral and physiological parameters, with assessment conducted by caretakers. Of the scales reviewed by the authors, the "FLACC" was chosen as appropriate for routine use due to its brevity and simplicity.

AIMS

Translation and establishment of reliability and validity of the Hebrew version of the FLACC.

METHODS

Subjects included 53 children aged 2 months to 8 years, who could not communicate verbally. Observations were conducted in the post-anesthesia care unit and the Intensive Care Unit. The FLACC was translated by the translation-back-translation technique. Inter-rater reliability was tested by two independent observers, and validity was assessed before and after provision of intravenous morphine or ketorolac.

RESULTS

Inter-rater reliability was high for the total FLACC score (r = 0.94, p < 0.001), as well as for the separate items (kappa 0.5-0.85). The FLACC was considered valid, as the change in scores paralleled the known pharmacological effect of the medications.

CONCLUSIONS

The Hebrew version of the FLACC was found reliable and valid for caretakers to use with children who cannot communicate verbally.

Leptin-induced increase in leukemia inhibitory factor and its receptor by human endometrium is partially mediated by interleukin 1 receptor signaling

Leptin and leukemia inhibitory factor (LIF) have been implicated as important mediators of implantation. The present study was designed to investigate whether leptin can directly regulate the expression of LIF and its receptor (LIF-R) in human endometrial cells and/or whether leptin-induced effects are linked to, or regulated in part by IL-1 signaling. Primary endometrial cells and endometrial epithelial cell lines (HES and Ishikawa cells) were cultured for 24-48 h in a medium containing insulin (5 microg/ml) and leptin (3, 10, and 62 nm) or IL-1beta (0.6, 3, and 10 nm) in the presence or absence of cytokines and/or receptor antagonists. The endpoints included phosphorylation of signal transducer and activator of transcription 3 (STAT3) and the relative levels of LIF, LIF-R, IL-1beta, IL-1 receptor antagonist (IL-1Ra) and IL-1 receptor type I (IL-1R tI) as determined by ELISA or Western blotting techniques. Leptin treatment increases the level of phosphorylated STAT3, LIF-R, and LIF. Leptin also increases the levels of IL-1 ligand, receptor, and antagonist as was previously reported. Blockade of OB-R with antibodies or with a specific OB-R inhibitor (leptin peptide antagonist-2) abrogated leptin-induced effects, suggesting that leptin binding to its receptor activates Janus kinase 2/STAT3 signaling. Treatment of endometrial cells with IL-1beta also results in elevated levels of LIF-R. Interestingly, the inhibition of IL-1R tI with a specific antibody or with IL-1Ra negatively affects both leptin-induced and IL-1-induced effects on LIF-R levels. Abnormal endometrial LIF expression has been associated with human infertility and leptin has profound effects on the levels of LIF, IL-1, and their cognate receptors in vitro. Thus, it is tempting to speculate that leptin's role in vivo could include the regulation of other key cytokines to be fundamental to endometrial receptivity during implantation (i.e. LIF and IL-1).

Determinants of radial artery pulse wave analysis in asymptomatic individuals

BACKGROUND

Noninvasive techniques to evaluate arterial stiffness include noninvasive radial artery pulse contour analysis. Diastolic pulse contour analysis provides a separate assessment of large (C1) and small artery (C2) elasticity. Analysis of the systolic pulse contour identifies two pressure peaks (P1 and P2) that relate to incident and reflected waves. This study aimed to compare indices from systolic and diastolic pulse contour analysis from the radial pressure waveform and to correlate these indices with traditional risk factors in asymptomatic individuals screened for cardiovascular disease.

METHODS

In 298 consecutive subjects (206 male and 92 female healthy subjects with a mean age of 50 +/- 12 years), noninvasive radial artery pressure waveforms were acquired with a piezoelectric transducer and analyzed for 1) diastolic indices of C1 and C2 from the CR-2000 CVProfiler, and 2) systolic indices of augmentation as defined by augmentation pressure (AP), augmentation index (AIx), and systolic reflective index (SRI = P2/P1). These indices were then correlated to each other as well as to individual traditional risk factors and the Framingham Risk Score.

RESULTS

Diastolic indices were significantly and inversely correlated to systolic indices with C2 showing a stronger inverse association than C1. C2 and Alx were significantly correlated with height, weight, and body mass index in men but not in women. All indices correlated better to blood pressure in women than men. In women, only systolic indices were significantly correlated to HDL cholesterol and only diastolic indices were significantly correlated to LDL cholesterol. All indices were significantly correlated to the Framingham Risk Score, which was stronger in women then men, but when adjusted for age only diastolic indices remained significant in women.

CONCLUSIONS

Diastolic and systolic indices of pulse contour analysis correlate differently with traditional risk factors in men and women.

The effect of vardenafil, a potent and highly selective phosphodiesterase-5 inhibitor for the treatment of erectile dysfunction, on the cardiovascular response to exercise in patients with coronary artery disease

OBJECTIVES

The effect of vardenafil, a potent and highly selective phosphodiesterase-5 (PDE5) inhibitor, on symptom-limited exercise time, time to first awareness of angina, and time to ischemic threshold (ST-segment depression > or =1 mm from baseline) during exercise tolerance testing (ETT) was examined in patients with stable coronary artery disease (CAD).

BACKGROUND

Erectile dysfunction (ED) is common among men with CAD. PDE5 inhibition is increasingly the preferred treatment option for ED. However, the effect of PDE5 inhibition on exercise-induced ischemia in CAD patients has received limited prospective evaluation.

METHODS

In this double-blind, crossover, single-dose multicenter study, 41 men with reproducible stable exertional angina due to ischemic CAD received vardenafil 10 mg or placebo, followed by ETT (5 to 10 metabolic equivalents [METS], Bruce protocol) 1 h postdose. Sublingual nitrate use was prohibited for > or =24 h pre- and postexercise study days. End points included symptom-limited treadmill exercise time, time to first awareness of angina, time to ischemic threshold, and safety.

RESULTS

Relative to placebo, vardenafil 10 mg did not alter exercise treadmill time (427 +/- 105 s vs. 433 +/- 109 s, p = 0.39), or time to first awareness of angina (292 +/- 110 s vs. 291 +/- 123 s, p = 0.59), but significantly prolonged time to ischemic threshold (334 +/- 108 s vs. 381 +/- 108, p = 0.0004). At peak exercise, vardenafil 10 mg did not alter blood pressure, heart rate, or rate-pressure product relative to placebo. The most common adverse events (facial flushing and headache) were of mild or moderate intensity, and short-lived.

CONCLUSIONS

Vardenafil 10 mg did not impair the ability of patients with stable CAD to exercise at levels equivalent or greater than that attained during sexual intercourse (average of 2.5 to 3.3 METS).

Epidemiology of suicide in Israel: a nationwide population study

BACKGROUND

In Israel, some population characteristics and lifestyle patterns make epidemiological research on suicide of particular interest. The Israeli population is characterized by ethnic diversity, with a multi-religious, multi-national mosaic of Jews and Arabs. These subgroups also vary in their suicidal behavior. The aims of the present study were to examine the trends in suicide incidence rates in Israel from 1984 to 1994, to identify sub-populations at high risk for suicide and to identify suicide methods associated with increased risk.

METHODS

Suicide rate trends in Israel over the period from 1984 to 1994 were examined for four subgroups: Jewish men and women, and Arab men and women. Cases of undetermined external cause (UEC) of death were also considered. Mortality data were obtained from the computerized data files of the Israeli Central Bureau of Statistics, which includes cause of death and sociodemographic variables. Suicide was classified according to the ICD-9 codes.

RESULTS

Suicide rates were higher for Jews than for Arabs, and higher for men than for women. The rates among both population and sex groups increased directly with age. A significant increase over the years studied was found for Jewish men, particularly in the 18- to 21-year-old age group. An increase in the use of firearms was noted, mainly in the groups in which total suicide rates increased.

CONCLUSIONS

The findings of this study highlight the need for further studies to identify both sub-populations at high risk for suicide, and societal trends such as lifestyles, immigration, military service, and media exposure to violence, as first steps toward planning of intervention programs to reduce suicide rates.

Using a health concerns checklist as a bridge from reason for encounter to diagnosis of girls attending an adolescent health service

OBJECTIVE

We assessed the extent to which a health concerns checklist (HCC) helps bridge the gap between the reason for encounter (RFE) described by girls entering an adolescent health service and the ultimate diagnosis.

METHODS

The sample, 547 consecutive 12- to 18-year-old girls visiting an adolescent health service, first underwent a structured intake procedure, including a self-administered form on which they described their RFEs and other health concerns, as well as a psychosocial interview and medical evaluation performed by staff members. The RFEs, HCC items, and diagnoses, grouped into somatic, sexuality-related, and psychosocial categories, were then compared.

RESULTS

Among the 399 girls expressing specific RFEs on entering the clinic, one-third were diagnosed with psychosocial disorders and one-fifth with sexuality-related concerns. Of the patients receiving a sexuality-related diagnosis, 57% presented with a sexuality-related request; another 26% noted it on the checklist. For those diagnosed with psychosocial problems, 22% stated this as the RFE, and another 50% indicated it on the HCC. The contribution of the HCC to the diagnosis was higher among adolescents not stating a specific RFE.

CONCLUSION

The findings highlight the HCC's contribution in identifying health problems, especially among adolescents who find it difficult to verbalize sensitive issues.

Postpartum depression in an Israeli cohort: demographic, psychosocial and medical risk factors

Demographic, psychosocial and medical risk factors for postpartum depression (PPD) were studied prospectively in a community cohort of 288 Israeli women. An Edinburgh Postnatal Depression Scale score of > or = 10 at 6 weeks postpartum was the criterion for PPD. Psychosocial risk factors were found to be the most potent. Lack of social support, marital disharmony, depressive symptoms during pregnancy, history of emotional problems and prolonged infant health problems were most predictive of PPD. The major role of psychosocial factors in PPD was similar to that found in other countries. The results were somewhat different for new Russian immigrants. These findings indicate that early identification of women at risk for PPD is feasible, and that consideration should be taken of subgroups that may be at heightened risk, or for whom risk factors play different roles.

[Depression scale for research in and identification of postpartum depression]

Postpartum depression (PPD) is a relatively frequent and serious condition, with negative consequences for the mother, her infant, and the family. From research and clinical experience in many countries, it has been found that PPD can be identified early, and women at risk for developing PPD can be identified before delivery in the framework of primary health care service. The Edinburgh Postnatal Depression Scale (EPDS) has been found valid for this purpose, both in the original English version, and in translation to numerous languages. The Hebrew translation of the EPDS is presented, and it is recommended that Israeli researchers use the same translation to facilitate accumulation of knowledge regarding the epidemiology of PPD and intervention strategies in various Israeli population groups, and for comparison with data from other countries.

Comparison of controlled-onset, extended-release verapamil with amlodipine and amlodipine plus atenolol on exercise performance and ambulatory ischemia in patients with chronic stable angina pectoris

This multicenter, randomized, double-blind, parallel group, placebo lead-in, placebo-controlled study compared the antianginal and anti-ischemic effects of once-daily bedtime dosing of controlled-onset extended-release (COER-24) verapamil to a once-daily morning dosing of amlodipine +/- atenolol in patients with chronic stable angina. A total of 551 patients with exercise-induced myocardial ischemia and evidence of coronary artery disease were randomized to a 4-week, forced-dose titration treatment period with (1) COER-24 verapamil 240 mg titrated to 480 mg at bedtime (n = 173), (2) amlodipine 5 mg titrated to 10 mg/day (n = 149), (3) amlodipine 5 mg (titrated to 10 mg) plus atenolol 50 mg/day in the A.M. (n = 154), or (4) placebo (n = 75). Treadmill exercise tolerance testing (standard Bruce protocol), and 48-hour ambulatory electrocardiographic (Holter) monitoring were performed at the end of placebo lead-in and double-blind treatment. Each active treatment significantly improved symptom-limited exercise duration and time to moderate angina (p < or = 0.01 vs placebo). For patients with baseline ischemia, amlodipine resulted in a statistically significant increase in total duration of ischemic episodes compared with placebo, whereas COER-24 verapamil and amlodipine plus atenolol resulted in statistically significant decreases compared with placebo and amlodipine. Heart rate at onset of ischemic episodes and ST product were also significantly increased with amlodipine (p < 0.05) compared with either COER-24 or amlodipine plus atenolol. COER-24 and amlodipine alone or in combination with atenolol improved exercise capacity in patients with angina pectoris. COER-24 verapamil monotherapy or amlodipine plus atenolol combination therapy were more effective than amlodipine monotherapy in decreasing ambulatory myocardial ischemia, especially during the hours of 6 A.M. to 12 noon.

Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors

This study aimed to assess the prevalence and incidence of postpartum depression (PPD) and to identify risk factors in a community cohort of Israeli-born, as well as new and veteran immigrant women. A random sample of 288 registrants at a community clinic was assessed for depressive symptoms at 26 weeks' pregnancy using the Beck Depression Inventory (BDI) and at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Information regarding risk factors was gathered through interviews and medical record abstracting. The prevalence of PPD was 22.6%. Two-thirds of the women had scored 'depressed' during pregnancy, and one-third (6.9%) were new incident cases. Immigrant status was the only significant demographic predictor of PPD identified by either univariate or multivariate analysis, with Russian new immigrants having over twice the risk for PPD as Israeli-born subjects. The rate of PPD in this Israeli cohort was comparable to that found in other countries. The finding that immigrant status was the most potent demographic predictor may support the role of stressful life events in the etiology of PPD. The use of the EPDS for PPD screening was found acceptable and feasible in the primary health setting.

Effect of pravastatin on cardiovascular events in women after myocardial infarction: the cholesterol and recurrent events (CARE) trial

OBJECTIVES

We sought to determine the effect of pravastatin on recurrent cardiovascular events in women with average cholesterol levels after myocardial infarction (MI).

BACKGROUND

Little information is available on the effectiveness of lipid lowering in secondary prevention of coronary heart disease (CHD) in women; in particular, those with CHD and average cholesterol levels.

METHODS

In the Cholesterol and Recurrent Events (CARE) trial, 576 postmenopausal women, between 3 and 20 months after MI, with a total cholesterol level <240 mg/dl and a low density lipoprotein cholesterol level 115 to 174 mg/dl, were randomized to receive pravastatin 40 mg/day or matching placebo for a median follow-up period of 5 years. The main outcome measures were combined coronary events (coronary death, nonfatal MI, percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass graft surgery [CABG]), the primary trial end point (coronary death or nonfatal MI) and stroke.

RESULTS

Women treated with pravastatin had a risk reduction of 43% for the primary end point (p = 0.035), 46% for combined coronary events (p = 0.001), 48% for PTCA (p = 0.025), 40% for CABG (p = 0.14) and 56% for stroke (p = 0.07). The 3,583 men in the CARE trial also showed a reduction in risk, but the magnitude tended to be less. Pravastatin improved plasma lipids similarly in men and women. There were no differences in risk of coronary events in the placebo group between men and women. Minor differences between men and women were present in baseline characteristics and treatment for MI, in general, conferring a higher risk status and a lower incidence of CABG in the women.

CONCLUSIONS

Pravastatin led to significant early reduction of a wide range of cardiovascular events in post-MI women with average cholesterol levels.

Mediators of estradiol-stimulated mitosis in the rat uterine luminal epithelium

The effects of estradiol treatment, which stimulates cell division in rat uterine epithelial cells, on the in vivo expression of heparin-binding epidermal growth factor (HB-EGF), cyclin D1, and cyclin B1 messenger RNA (mRNA) in these cells have been examined using ribonuclease protection assays. Estradiol gave rise to significant increases in steady state levels of HB-EGF 2 and 24 h after treatment. Cyclin D1 mRNA levels were elevated 8 and 10 h after estradiol administration, corresponding to the G1 phase of the mitotic cycle, and cyclin B1 mRNA was only expressed 16-24 h after estradiol treatment, which corresponds to the G2 and M phases of the rat uterine epithelial cell cycle. Estradiol-stimulated increases in HB-EGF mRNA were not affected by treatment with cycloheximide, but were inhibited by the estrogen antagonist compound, ICI 164,384, demonstrating that the estrogen-stimulated increase in HB-EGF mRNA is a primary, estrogen receptor-mediated response of rat uterine epithelium to estradiol. Progesterone treatment, which blocks epithelial cells in G1 of the cycle, suppressed levels of HB-EGF mRNA below those observed in ovariectomized rats. These results indicate that HB-EGF mediates the regulatory effects of both estradiol and progesterone on rat uterine epithelial cell proliferation through an effect on the production of G1 phase molecules such as cyclin D1.

Antianginal response to once-daily diltiazem CD in patients receiving concomitant beta-blockers, long-acting nitrates, or both. Diltiazem CD Study Group

STUDY OBJECTIVE

To determine the safety and efficacy of diltiazem CD 180 mg administered once/day in patients with chronic stable angina inadequately controlled with P-blockers, long-acting nitrates, or both.

DESIGN

Multicenter, randomized, double-blind, placebo-controlled, parallel-group trial.

SETTING

Medical clinics in the private and academic sectors.

PATIENTS

Of 172 patients, 170 completed the 2-week double-blind treatment period.

INTERVENTION

. Patients received either diltiazem CD 180 mg or placebo once/day in combination with existing antianginal therapy.

MEASUREMENTS AND MAIN RESULTS

The time to termination of exercise tolerance testing, 24 hours after the dose increased significantly in the diltiazem CD group (37.2 sec) compared with the placebo group (21.3 sec, p=0.0438). Time to onset of angina during exercise testing also increased (57.6 vs 35.0 sec, respectively, p=0.0324), as did time to moderate angina (37.5 vs 20.6 sec, respectively, p=0.0354). The rates of total angina attacks and of angina attacks on exertion were significantly reduced in the diltiazem CD group versus placebo (p<0.05). Significant reductions in systolic and diastolic blood pressures and heart rate-blood pressure product measured at rest, submaximum exercise, and exercise termination were observed in diltiazem CD-treated patients compared with placebo (p<0.05). The frequency of treatment-related adverse events was identical in the two groups, 15.1%.

CONCLUSION

Diltiazem CD 180 mg once/day is an effective, safe, and beneficial initial dosage when added to existing antianginal therapy.

Dose-response evaluation of once-daily therapy with a new formulation of diltiazem for stable angina pectoris. Diltiazem CD Study Group

Diltiazem hydrochloride in a once-daily capsule formulation (DCD) has recently been approved in the United States for the treatment of mild to moderate hypertension and chronic stable angina pectoris. This trial evaluated the dose response of DCD in patients with chronic stable angina pectoris. In a multicenter, randomized, double-blind, parallel-design trial, the effects and tolerability of once-daily therapy with placebo or DCD (60, 120, 240, 360, or 480 mg) were evaluated 24 hours after dosing, following 3 weeks of therapy in 227 patients with reproducible stable exertional angina pectoris. A significant linear dose trend (p = 0.004) was present across the 6 treatment groups for the primary end point--time to exercise termination at 24 hours after dosing--using a standard Bruce treadmill exercise test. A significant linear dose trend was also seen for time to 1 mm ST-segment depression at 24 hours after dosing. Similar effects on exercise parameters were also seen at 4 hours after dosing. A linear dose trend (p = 0.04) was noted relative to the overall anginal attacks during daily activities and for anginal attacks during exercise (p = 0.02). Overall frequency of treatment-related adverse effects was dose-related and occurred in 24.4% and 17.5% of patients treated with DCD and placebo, respectively. At a dose up to 240 mg/day, improvement in exercise tolerance was achieved without an associated increase in the rate of treatment-related adverse events compared with placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

Heparin-binding epidermal growth factor-like growth factor is differentially regulated by progesterone and estradiol in rat uterine epithelial and stromal cells

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) cDNA was isolated from a subtracted cDNA library that selected for progesterone-induced transcripts from rat uterine stromal cells. In this study, the effects of progesterone and estradiol on the expression of HB-EGF in mature rat uterine epithelial and stromal cells have been examined. RNase protection assays and in situ hybridization demonstrated that progesterone stimulated expression of HB-EGF in rat uterine stromal cells, but repressed levels of HB-EGF mRNA in luminal and glandular epithelial cells. In contrast, estradiol treatment strongly enhanced HB-EGF expression in epithelial cells, but had no effect on mRNA levels for this growth factor in stromal cells. Progesterone treatment followed by estradiol injection stimulated HB-EGF expression in stromal cells and repressed expression in luminal and glandular epithelium. Stimulation of HB-EGF expression in stromal cells by progesterone was not inhibited by treatment with cycloheximide, demonstrating that HB-EGF mRNA expression is a primary response of stromal cells to progesterone. These results reveal that expression of HB-EGF is stimulated in epithelial and stromal cells in vivo under the same hormonal conditions that induce cell proliferation in each of these cell types and strongly suggest that HB-EGF may mediate the mitogenic effects of steroid hormones in the rat uterus.

[Health profile of children without medical insurance]

Lack of medical insurance is a health risk factor. Underutilization or postponement of medical services, as well as lack of planning for long-term care are common among the uninsured, project was implemented within the framework of the Or Yehuda Intervention Program to assess the health status of children from birth to 17 years of age in 72 families without health insurance. Information on medical status and service utilization was summarized for 169 of the 217 children in these families. These families constituted a substantial burden on the health system, both in the form of hospitalization debt (636 hospital-days owed to a nearby hospital) and as uncompensated primary care clinic visits. Half of the visits were made by 12% of the children, while a quarter of the study children had not visited the clinic at all during the preceding year. Among families uninsured for over 2 years, the trend of underutilization was even more pronounced. Significant morbidity and signs of neglect were found among the study children, nearly 60% of whom suffered from health problems and a similar proportion had been hospitalized. The most common diagnoses were infections, congenital anomalies, and musculoskeletal and hematological problems; a third of the children had 2 or more conditions. Over 40% of the study children were referred for specialist consultation or treatment--about half of them to the pediatric subspecialties and the other half to surgical clinics. Signs of medical neglect were noted in 42.6% of study children and among 60.4% of those with 2 or more medical problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety and efficacy of metoprolol in the treatment of hypertension in the elderly

OBJECTIVE

To assess the short-term efficacy and safety of metoprolol in the treatment of hypertension in a large population of older patients.

DESIGN

Prospective, open-label surveillance study.

SETTING

Multicenter outpatient offices.

PARTICIPANTS

21,692 patients with mild-to-moderate hypertension between the ages of 50 to 75 years. Patients were excluded if they had a contraindication to beta-blocker therapy.

INTERVENTION

Patients were treated with 100 mg of metoprolol once daily for 4 week. If the blood pressure was controlled, therapy was continued for an additional 4 weeks. If adequate blood pressure was not achieved after 4 weeks, 25 mg of hydrochlorothiazide was added. At the end of 8 weeks, final therapy decisions were recorded. If the blood pressure was controlled, therapy was continued for an additional 4 weeks.

MAIN OUTCOME MEASURES

Blood pressure, heart rate and side-effects.

RESULTS

After 4 weeks of therapy, mean systolic and diastolic blood pressures decreased significantly from 162/95 to 148/87 mm Hg (P less than 0.001). Fifty-eight percent of the patients had satisfactory blood pressure control. At the end of 8 weeks, mean systolic and diastolic blood pressure decreased to 143/84 mm Hg. Blood pressure response was similar in all age groups. At the termination of the study, 50% of the patients were continued on monotherapy, and 27% were continued on combined therapy. Overall, there was less than a 5% incidence of medical problems, and excellent or good tolerability was noted for 94% of the patients.

CONCLUSIONS

Metoprolol administered as monotherapy or in combination with hydrochlorothiazide was effective in normalizing blood pressure in a majority of elderly hypertensive patients. Both drug regimens were well tolerated.

Double-blind, dose-response, placebo-controlled multicenter study of nisoldipine. A new second-generation calcium channel blocker in angina pectoris

BACKGROUND

Nisoldipine is a potent 1:4 dihydropyridine calcium channel antagonist, and doses of 5 or 10 mg administered either once or twice daily have been claimed to exert antianginal effects. There is, however, little information regarding the dose-response relation and whether the drug exerts any consistent effects throughout the dosing interval. In this placebo-controlled, parallel-design study, the dose-response relation of monotherapy with nisoldipine administered twice daily was studied in patients with stable angina pectoris.

METHODS AND RESULTS

Two hundred thirty-one patients received single-blind placebo for 2 weeks; of these, 185 patients who reproducibly stopped treadmill exercise because of angina of moderate severity and had greater than or equal to 1 mm ST segment depression during exercise and experienced an average of three episodes of anginal attacks per week were randomized in a double-blind manner to one of the four treatment groups: placebo (n = 48), nisoldipine 2.5 mg (n = 47), nisoldipine 5 mg (n = 44), or nisoldipine 10 mg (n = 46). Nisoldipine or placebo was administered twice daily for 4 weeks and symptom-limited exercise tests were repeated at 2 and 10-14 hours after the double-blind medication. One hundred sixty-eight patients completed the study and 181 patients were valid for efficacy analysis. Compared with double-blind placebo, there were marginally significant trends toward increases for time to onset of angina for the 10-mg-b.i.d. group (83 versus 108 seconds, p = 0.08), time to 1 mm ST segment depression for the 5-mg-b.i.d. group (54 versus 83 seconds, p = 0.08), and total exercise time for the 5- (30 versus 50 seconds, p = 0.10) and 10-mg-b.i.d. (30 versus 58 seconds, p = 0.06) groups at 2 hours after the dose (peak effect) after 4 weeks of therapy. At 10-14 hours after the dose (trough effect), no differences between placebo and any of the nisoldipine doses on any of the exercise parameters were found after 4 weeks of therapy. A subset analysis of patients who stopped exercise within 10 minutes because of angina of moderate severity during single-blind placebo therapy (n = 123) revealed significant increase in total exercise duration and time to 1 mm ST segment depression at 2 hours after the dose in the 5- and 10-mg-b.i.d. dose groups compared with double-blind placebo (p less than 0.04). No significant trough effects, however, were observed even in this subgroup after any of the doses of nisoldipine. The frequency of anginal attacks decreased by 44%, 41%, 30%, and 41% after twice-daily therapy with 2.5 mg, 5 mg, 10 mg nisoldipine, and placebo groups, respectively (p = NS, nisoldipine versus placebo). The incidence of adverse events (minor and major) was 43.8% in the placebo group and 42.6%, 45.5%, and 56.5% in the nisoldipine 2.5-, 5-, and 10-mg-b.i.d. groups, respectively (p = NS compared with placebo). However, four patients developed unstable angina while on nisoldipine therapy (two in the 2.5-mg, one in the 5-mg, and one in the 10-mg-b.i.d. group) and two patients died suddenly in the nisoldipine 10-mg-b.i.d. group.

CONCLUSIONS

Monotherapy with 2.5, 5, and 10 mg nisoldipine twice a day was not superior to placebo therapy in treating patients with angina pectoris, and the 10-mg-b.i.d. therapy resulted in a statistically insignificant but clinically important increase in the incidence of serious adverse events.

A cluster of repetitive elements within a 700 base pair region in the mouse genome

Approximately 39% of the clones from a BALB/c mouse genomic library hybridized with polyadenylated cytoplasmic RNA extracted from anemic mouse spleen. The DNA sequence of a portion of one such clone revealed the presence of three repetitive sequence elements within a 700 bp span. All three elements contain putative RNA polymerase III control regions oriented in the same direction and oligo(dA) tracts at their 3' ends. The first element is a member of the murine B1 family. A comparison of this element with other B1 family members indicates that the B1 family can be divided into two subclasses based on commonly held base changes and deletions. The second element within this 700 bp region may be a member of a new murine Alu family. Its structure is analogous to other murine Alu-equivalent sequences with respect to overall length, the presence of a 3' oligo(dA) tract and putative RNA polymerase III control regions. The third element is a murine type 2 Alu-equivalent sequence.

Ichthyosiform sarcoid

Although acquired ichthyosis may appear in patients with various systemic illnesses, an association with with sarcoidosis has rarely been reported. However, three adults who presented with sarcoidosis and ichthyosiform changes on their legs are discussed herein.