Pediatric dysphagia overview: best practice recommendation study by multidisciplinary experts

BACKGROUND

Currently, there is no comprehensive and multidisciplinary recommendation study covering all aspects of pediatric dysphagia (PD). This study aimed to generate PD management recommendations with methods that can be used in clinical practice to fill this gap in our country and in the world, from the perspective of experienced multidisciplinary experts.

METHODS

This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-round modified Delphi survey via e-mail. First, ten open-ended questions were created, and then detailed recommendations including management, diagnosis, treatment, and follow-up were created with the answers from these questions. Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation) and divergent consensus (not recommended).

RESULTS

In the 1st Delphi round, a questionnaire of 414 items was prepared based on the experts' responses to ten open-ended questions. In the 2nd Delphi round, 59.2% of these items were accepted as pre-recommendation. In the 3rd Delphi round, 62.6% of 246 items were accepted for inclusion in the proposals. The final version recommendations consisted of 154 items.

CONCLUSIONS

This study includes comprehensive and detailed answers for every problem that could be posed in clinical practice for the management of PD, and recommendations are for all pediatric patients with both oropharyngeal and esophageal dysphagia.

The Relationship Between Serum Angiogenic Factor Levels and Disease Activity in Rheumatoid Arthritis

Objectives

This study aims to evaluate the relationship between serum angiogenic factor levels and disease activity in patients with rheumatoid arthritis (RA) using both clinical and dynamic wrist magnetic resonance imaging (MRI) data.

Patients and methods

Simultaneous serum angiogenesis markers [vascular endothelial growth factor (VEGF), angiopoietin-1 (ANG1), ANG2, and tyrosine-protein kinase receptor for angiopoietin (Tie-2)] were studied in 40 patients with RA (13 males, 27 females; mean age 51.1±10.8 years; range, 23 to 69 years) and 20 healthy controls (11 males, 9 females; mean age 47.3±12.8 years; range, 29 to 69 years) and dynamic contrast-enhanced wrist MRI was performed in 40 RA patients and seven controls. Rate of early in 55th second (REE) and Relative enhancement (REt) values were calculated from the signal time curve values obtained from the analysis of images. In clinical assessment, duration of morning stiffness, patient pain assessment [visual analog scale (VAS)], physician and patient global assessments (VAS) were recorded. The number of tender joints and swollen joints were determined. Disease activity score 28 and Ritchie scores were calculated. Health assessment questionnaire was used for functional evaluation. Anti-cyclic citrullinated peptide, rheumatoid factor, erythrocyte sedimentation rate and high sensitive C-reactive protein analyses were performed.

Results

Serum VEGF, REE and REt values were significantly higher in RA patients than healthy controls (p=0.002, p=0.00, p=0.00, respectively). There was no significant correlation between serum angiogenesis markers and clinical parameters or REE and REt (p>0.05). VEGF value correlated positively with disease duration (p=0.024).

Conclusion

Serum VEGF was higher in RA patients. While its level was associated with disease duration, no significant correlation was found with disease activity. As a diagnostic test, dynamic contrast-enhanced MRI was a valuable method for showing disease activity.

Comparison of OMERACT-RAMRIS scores and computer-aided dynamic magnetic resonance imaging findings of hand and wrist as a measure of activity in rheumatoid arthritis

The purpose of this study was to compare the value of conventional magnetic resonance imaging (MRI) finding of rheumatoid arthritis (RA) and computer-aided dynamic MRI measurements in predicting the activity of disease. The activity of the disease in 40 RA patients was evaluated by the disease activity score in 28 joints (DAS28). The conventional MRI of the wrists of all patients were scored for bone edema, synovitis and erosions, according to the criteria of RA-MRI scoring system (RAMRIS) developed by Outcome measures in rheumatology clinical trials (OMERACT) MR Imaging Group. Synovitis was also quantified by dynamic postcontrast MRI imaging using color coded maximum slope of increase maps and measurements of early enhancement rate (EER) and relative enhancement (RE). Twenty-two (55 %) patients with a score higher than 5.1 constituted the high disease activity group, 18 (45 %) patients with a score of 5.1 or less constituted moderate disease activity group. The dynamic MRI-EER score was the most significant parameter to differentiate between the groups (p = 0.001). Among OMERACT scores, only bone edema [p = 0.020 for wrist and p = 0.037 for metacarpophalangeal joints (MCP)] had a significant difference between the two groups. Dynamic MRI RE score and OMERACT scores for erosions and synovitis for both the wrist and MCP joints did not differ significantly between the two groups. Computer-aided dynamic MRI is a reliable, noninvasive method of evaluating the RA patients, which correlates with the DAS28 scores, at a higher significance than the OMERACT-RAMRIS scores.

Effects of physical exercise on lung injury and oxidant stress in children with asthma

BACKGROUND

The aim of this study was to investigate the influence of exercise training on oxidative stress and markers of lung inflammation in children with asthma.

METHODS

Thirty children aged 8-13 years diagnosed with asthma were enrolled in the study as well as 13 healthy children. One group received only pharmacological treatment and the other group was also enrolled in an exercise programme. Venous blood and 24-hour urine samples were obtained from the children enrolled in the study at the beginning and end of the study. Leukotriene E4 and creatinine levels were measured in the urine and matrix metallopeptidase (MMP-9), endothelin-1(ET-1), malnodialdehyde (MDA), IgE and specific IgE levels were measured in blood samples.

RESULTS

Leukotriene E4, MDA and MMP9 levels decreased significantly with treatment in both groups (p < 0.001). However, ET-1 levels decreased significant only in the exercise group (26.5 ± 3.6 vs 21.3 ± 2.4 pg/ml respectively, p = 0.001). Moreover, ET-1 levels were found to be significantly lower in the exercise group compared to the only pharmacotherapy group (24.2 ± 3.1 vs 21.3 ± 2.4 pg/ml, p=0.007).

CONCLUSIONS

Positive influences of exercise training in children with asthma may be mediated by decrease in ET-1 levels.

The beneficial effects of physical exercise on antioxidant status in asthmatic children

BACKGROUND

The pathogenesis of asthma involves both airway inflammation and an oxidant/antioxidant imbalance. It is demonstrated in asthmatic adults that exercise programmes improve lung function, a mechanism yet to be elucidated. The purpose of this study was to investigate the possible beneficial effects of physical exercise on antioxidant status in asthmatic children which may lead to ameliorated lung function.

METHODS

The study enrolled thirteen control and thirty asthmatic children. The asthmatic group was subdivided into two: the first group receiving only pharmacological treatment (n=15) and the second receiving pharmacological treatment with exercise programme (n=15) for 8 weeks. Blood samples were drawn from the subjects before and after treatment periods. As oxidant stress markers blood levels of malondialdehyde (MDA) and total nitric oxide (NO), and as antioxidant status, glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD) enzyme activities were assessed.

RESULTS

Before any treatment was initiated, MDA and NO levels in the asthmatic group were significantly higher than the controls (3.40±0.96 nmol/ml vs 2.46±0.58 nmol/ml, and 12.53±2.10 vs 9.40±1.39 micromol/L, respectively). Both SOD (p=0.0001) and GSH-Px (p=0.023) activities were significantly lower in the asthmatic group. Pharmacological treatment and exercise programme together significantly improved lung performance and decreased the levels of oxidant stress markers, in concordance with a significantly increase in antioxidant enzyme activity measures when compared to the pharmacological treatment.

CONCLUSION

Structured exercise programme in asthmatic children resulted in better lung function, which may be attributed to its effect on antioxidant status.

The effect of anti-tumor necrosis factor (TNF)-alpha therapy with etanercept on endothelial functions in patients with rheumatoid arthritis

OBJECTIVE

To investigate the effects of tumor necrosis factor (TNF)- alpha antagonism with etanercept (ENC) on endothelial functions in patients with active rheumatoid arthritis (RA).

METHODS

A total of 21 patients with RA were enrolled in this prospective study. Eleven of them (8 women, 3 men mean age 47.0+/-10.1 years) with high disease activity despite the conventional treatment were assigned to Group 1 and were given ENC treatment twice a week (25 mg SC injection) for 12 weeks. Ten patients with RA (8 women, 2 men mean age 55.0+/-6.4 years) under conventional methotrexate and prednisone therapy were assigned as Control group (Group 2). Endothelium-dependent and -independent vasodilator responses of the brachial artery were assessed by high-resolution ultrasound. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were also measured at baseline and at the post treatment period. Mann-Whitney U and Wilcoxon tests were used to compare the data and correlation analysis was performed using Pearson correlation test.

RESULTS

Endothelium-dependent vasodilatation improved from 5.2+/-0.8% to 7.9+/-1.3% (p=0.04) in ENC group, while no significant change was observed in the control group (from 6.6+/-1.1% to 7.0+/-1.8% p=0.67). No significant changes were found in endothelium-independent vasodilatation and baseline brachial artery diameters in both groups. A significant reduction in ESR and CRP were observed in patients receiving ENC (from 16.2+/-6.8 to 9.2+/-5.1 mm/h, p=0.003 and from 14.68+/-3.4 to 9.25+/-3.7 mg/L, p=0.003, respectively).

CONCLUSION

Treatment with ENC for 12 weeks significantly improved endothelial function in patients with active RA compared to those under conventional therapy. The findings of the present study support the hypothesis that the use of TNF-alpha blockers in patients with active RA may reduce the high incidence of cardiovascular complications.

The effects of botulinum-A toxin on bladder function and histology in spinal cord injured rats: is there any difference between early and late application?

PURPOSE

We explored the effects of early and late application of botulinum-A toxin (BTX-A) on reservoir function and histological bladder changes in spinal cord injured rats.

MATERIALS AND METHODS

The study was done in 30 Sprague-Dawley rats randomly allocated into 5 groups. Group 1 of 6 rats underwent sham operation only. Group 2 of 6 rats underwent spinal cord transection. Group 3 of 6 rats underwent spinal cord transection followed by BTX-A application into the detrusor muscle 7 days later. Group 4 of 6 rats underwent spinal cord transection, followed by BTX-A application into the detrusor muscle 28 days later. Group 5 of 6 rats underwent spinal cord transection followed by saline injection into the detrusor muscle after 28 days. Spinal cord injury was created by transecting the cord at the T9 to T10 level. All rats underwent cystometric examination initially and on day 42 before sacrifice. The bladders were removed and examined histologically for fibrosis and hyperplasia.

RESULTS

On cystometric examination BTX-A caused an improvement in baseline pressure, and the frequency and amplitude of uninhibited detrusor contractions (p <0.001). No significant differences were observed in maximal bladder capacity or urethral opening pressure (p >0.05). Histologically BTX-A led to decreased fibrosis and hyperplasia (p <0.001). No significant differences were found between histological or cystometric among the groups with respect to receiving BTX-A in the early and late periods (p >0.05).

CONCLUSIONS

BTX-A has a functional and histological healing effect on detrusor hyperreflexia subsequent to spinal cord injury in rats. Although administering BTX-A in the early period had better quantifiable functional and histological outcomes compared to the late period, the difference was not statistically significant.

Effects of Angiotensin-converting enzyme inhibition and statin treatment on inflammatory markers and endothelial functions in patients with longterm rheumatoid arthritis

OBJECTIVE

To investigate the effects of angiotensin-converting enzyme (ACE) inhibitors and statins (hydroxy-methyl-glutaryl-CoA reductase inhibitors) on inflammatory markers and endothelial functions in patients with rheumatoid arthritis (RA).

METHODS

A total of 45 patients with longterm RA were randomized into 3 groups to receive 8 weeks of treatment with placebo (n = 15), simvastatin (20 mg/day, n = 15), or quinapril (10 mg/day, n = 15) as an adjunct to existing antirheumatic drug treatment. Factors with a role in the development of endothelial dysfunction, such as C-reactive protein (CRP), fibrinogen, nitric oxide (NO), and serum cytokine concentrations including interleukin 1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha (TNF-alpha) were measured at baseline and in the posttreatment period. Brachial artery vasodilator responses were assessed by high resolution ultrasound to evaluate endothelial functions.

RESULTS

Simvastatin treatment significantly decreased serum CRP and TNF-a [from 14 +/- 6 to 7 +/- 3 mg/l (p = 0.025) and 30 +/- 5 to 16 +/- 4 pg/ml (p = 0.012), respectively], while quinapril had no significant changes in these 2 measures. IL-1beta and IL-6 showed insignificant changes in patients in the 2 drug groups. Endothelium-dependent vasodilatation was improved significantly in the simvastatin group [from 5.3 +/- 1.1% to 8.9 +/- 1.4% (p = 0.025)], while there was no difference in endothelium-independent vasodilatation [9.0 +/- 1.8% to 11.2 +/- 2.5% (p = 0.17)]. The quinapril group showed no significant changes in both types of vasodilation although there was a tendency to an increase in endothelium-dependent vasodilatation [from 6.1 +/- 0.8% to 7.8 +/- 0.7% (p = 0.06)]. Treatment with the 2 drugs had no significant effects on resting arterial diameter.

CONCLUSION

We show that simvastatin 20 mg daily improves endothelial function in patients with RA. Its beneficial effect may be attributed to lowering CRP and TNF-alpha concentrations. ACE inhibition with daily 10 mg quinapril was found to have no significant effects on inflammatory markers and endothelial vasodilator response.

SEXUAL DYSFUNCTION IN FEMALE SUBJECTS WITH FIBROMYALGIA

PURPOSE

We investigated sexual function in females with fibromyalgia (FM) and evaluate whether coexistent major depression (MD) has an additional negative effect on sexual function.

MATERIALS AND METHODS

A total of 100 female subjects were enrolled in the study, including 40 with FM only, 27 with FM plus MD and 33 healthy volunteers as a control group. The diagnosis of MD was made according to Structured Clinical Interview for Diagnostic and Statistical Manual-IV interview and the Hamilton Depression Rate Scale was used to grade depression. Widespread pain and quality of life were assessed with the Lattinen Pain Scale and Fibromyalgia Impact Questionnaire, respectively. The Female Sexual Function Index (FSFI) was used to assess sexual dysfunction.

RESULTS

All subjects were comparable in age, occupation and education. Mean FSFI total score +/- SD was significantly decreased in the FM and FM plus MD groups compared with that in healthy controls (21.83 +/- 5.84 and 22.43 +/- 7.0 vs 28.10 +/- 6.52, respectively, p = 0.001). However, the FSFI score was not significantly different between patients with FM only and FM plus MD (p >0.05). Correlation analysis revealed a negative moderate correlation between total Lattinen pain score and FSFI score in the FM only and FM plus MD groups (r = -0.366, p = 0.047 and r = -0.403, p = 0.018, respectively). FSFI score did not correlate with FIQ and HDRS scores (p >0.05).

CONCLUSIONS

This study demonstrates that female patients with FM have distinct sexual dysfunction compared with healthy controls and coexistent MD has no additional negative effect on sexual function. Thus, female subjects with FM should be evaluated in terms of sexual function to provide better quality of life.

Selective COX-2 inhibition with different doses of rofecoxib does not impair endothelial function in patients with coronary artery disease

In this study, we investigated the effects of both 25 and 50 mg daily doses of rofecoxib on the endothelial functions of patients with coronary artery disease (CAD). For this purpose, 34 patients with documented severe CAD and who were under aspirin treatment (300 mg/day) were randomized to receive 4 weeks of treatment with a placebo (n = 10, group I), rofecoxib 25 mg/day (n = 12, group II), and rofecoxib 50 mg/day (n = 12, group III). Brachial artery vasodilator responses were measured in order to evaluate endothelial function. The percentage of change in endothelial-dependent vasodilation in groups I, II, and III were similar at the baseline level and showed no significant change after treatment (6.2+/-3.9% vs. 5.9+/-3.1% and 5.8+/-3.3% vs. 5.6+/-3.8% and 6.1+/-4.5% vs. 5.8+/-4.1%, respectively; P > 0.05). Compared with the baseline, endothelium-independent vasodilatation, as assessed by nitroglycerine (NTG), remained unchanged after the treatment period (11.2+/-6.9% vs. 10.3+/-7.1% and 11.2+/-6.3% vs. 9.9+/-5.1% and 9.5+/-4.9% and 8.8+/-4.6%, respectively; P> 0.05). Treatment with both doses also showed no significant effects on high-sensitivity C-reactive protein (hs-CRP) levels and resting arterial diameters (P > 0.05). In conclusion, 4 weeks of treatment with standard and high doses of rofecoxib showed no significant effects on either endothelial-dependent or independent vasodilator response or plasma hs-CRP levels in patients with severe CAD taking concomitant aspirin.

Endothelıal dysfunctıon ın patıents wıth prımary Sjögren’s syndrome

The aim of this study was to determine the endothelial function in patients with primary Sjögren's syndrome (SS). We also aimed to determine whether endothelial (dys)function correlates with extraglandular manifestations, specific autoantibodies and the severity of salivary gland involvement of SS. Endothelium-dependent vasodilation and endothelium-independent vasodilation of the brachial artery were assessed by a high-resolution ultrasound on 25 patients with primary SS and on 29 healthy controls. Patients with primary SS had significantly less mean endothelium-dependent vasodilation than did controls (3.0 +/- 0.4% vs 4.2 +/- 0.3%; p = 0.012). Endothelium-independent vasodilation induced by sublingual glycerol trinitrate was not different between the two groups (12.9 +/- 1.4% vs 14.1 +/- 1.2%; p = 0.86). We concluded that endothelium-dependent vasodilation was impaired in primary SS patients, in particular those presenting with Raynaud's phenomenon, when compared with the healthy controls and this impairment was not associated with the presence of RF, ANA, anti-Ro/SS-A, anti-La/SS-B and with the other extraglandular manifestations of the disease.

Effects of simvastatin on bone mineral density and remodeling parameters in postmenopausal osteopenic subjects: 1-year follow-up study

Observational studies suggest that statin use may be associated with lower incidence of fracture. However, there are conflicting data for their effects on bone remodeling parameters and bone mineral density (BMD). In the present study, we aimed to investigate the effects of simvastatin on bone metabolism and BMD in subjects with hypercholesterolemia (>240 mg/dl). For this purpose, 32 postmenopausal osteopenic subjects who were given simvastatin treatment (20 mg/day) and not on osteoporosis treatment were included in the study. During the 1-year follow-up period, the total cholesterol level decreased from 262.1+/-30.9 to 202.2+/-30.1 mg/dl (p<0.0001). At a period as early as the 3rd month, levels of the anabolic markers, e.g., bone-specific alkaline phosphatase (BSAP) and osteocalcin (OCL), were found to be significantly increased (from 120.8+/-56.6 to 149.5+/-57.6 IU/l, p=0.008, and from 20.8+/-12.6 to 34.7+/-18.4 microg/l, p=0.015, respectively) while no significant change was observed in the resorptive marker of serum N-telopeptide of type I collagen (CTX). At the 6th and 12th month, BSAP and OCL were both found to be decreased below the pretreatment values. While a significant reduction was found in BSAP levels (from 120.8+/-56.6 to 55.9+/-18.8 IU/l, p<0.001), no significant change was observed in CTX levels after the 6-month treatment period. Parathyroid hormone showed a gradual profound increase during the follow-up period (from 62.7+/-41.5 to 108.4+/-51.7 pg/ml, p<0.001). No significant change was found in BMD levels at the spine, femoral neck, Ward's triangle, and trochanter at the end of the 1-year follow-up period. In conclusion, simvastatin treatment showed a short-lasting anabolic effect on bone metabolism. However, this effect was lost by prolongation of therapy. The decrease in both anabolic and resorptive markers at the 6th and 12th month suggests that simvastatin affects bone metabolism mostly in favor of inhibition of the bone turnover in a long-term observation period although this inhibitory effect was not reflected in BMD.

Comparison of the efficacy of lower and higher molecular weight viscosupplementation in the treatment of hip osteoarthritis

We aimed to compare the efficacy of intra-articular injections of a lower molecular weight hyaluronan (LMW HA) (Ostenil) with a higher molecular weight viscosupplement (hylan G-F 20, Synvisc) in hip osteoarthritis. For this purpose, 43 patients (56 hips) with hip osteoarthritis with a visual analogue scale (VAS) pain score higher than 50/100, a Lequesne index greater than 6, and persistence of the pain for longer than 3 months despite all conservative methods were enrolled in the study and randomly assigned to two groups: 25 (32 hips) received LMW HA and the remaining 18 patients (24 hips) received hylan G-F 20. Three injections were administered once weekly to each patient under fluoroscopic guidance. During the 6-month follow-up period, the primary outcomes were assessed at the 1st, 3rd, and 6th month by VAS, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and Lequesne index. The intra-articular injections produced a significant reduction in VAS, WOMAC, and Lequesne index scores in both groups. After three injections, improvement was prominent at the 1st month and maintained for 6 months in both groups. The percentage reduction was 38 and 40% (p<0.001) in VAS pain score, 43 and 40% in WOMAC (p<0.001), and 47 and 49% in Lequesne index (p<0.001) in the LMW HA and hylan G-F groups at the 6th month, respectively. However, there were no significant differences in outcomes between any of the measurements at the 1st, 3rd, and 6th month between the two groups (p>0.05). No systemic adverse effect was recorded. Local adverse effects consisting of pain and/or swelling were noted in 3 of 32 hips (9%) injected with LMW HA and in 3 of 24 hips (12.5%) injected with hylan G-F 20. In conclusion, both types of viscosupplementation produced a significant clinical improvement during the 6-month follow-up period. However, no significant difference was found in outcomes between higher and lower molecular weight hyaluronan.

Comparison of the effects of alendronate and risedronate on bone mineral density and bone turnover markers in postmenopausal osteoporosis

The aim of the study was to compare the effects of once-weekly alendronate sodium and daily risedronate sodium treatment on bone mineral density (BMD) and bone turnover markers in postmenopausal osteoporotic subjects. For this purpose, 50 patients were included in this study and randomly classified into two groups. Group I (n=25) received risedronate (5 mg/day) and group II (n=25) received alendronate Na (70 mg/week). The study duration was limited to 12 months. The efficacy of the treatment was evaluated by BMD measurements at spine and hip at 6th and 12th months of the treatment, as well as by the measurement of bone turnover markers such as serum osteocalcin (OC), bone-specific alkaline phosphatase (BASP), urine deoxypyridinoline (DPD) and calcium/creatine ratio in 24-h urine at 1st, 3rd, 6th and 12th months. The evaluation of the changes in BMD in all regions revealed a significant increase in BMD in both groups compared to baseline values except for spine (L2-L4) in alendronate group at 6th and 12th month and femoral neck in risedronate group at 6th month. However, the difference in percentage increase in BMD measurements was not statistically significant between the two groups at 6th and 12th months. In both groups, serum OC, BSAP and urine DPD were found to be significantly attenuated at 1st month of the treatment period, and continued to be lowered throughout the 3rd, 6th and 12th months (P<0.05). However, there was no statistically-significant difference between both groups of patients (P>0.05). In conclusion, our results suggest that both treatment protocols provide treatment options of similar efficiency for postmenopausal osteoporosis, and have almost-similar effects in enhancing the BMD and in slowing the bone turnover. Risedronate seems to have a more potent effect in the spinal region than that of alendronate, although this potency was not statistically significant.

The effect of simvastatin on serum cytokine levels and bone metabolism in postmenopausal subjects: negative correlation between TNF-alpha and anabolic bone parameters

In this prospective study, we aimed to evaluate the effect of simvastatin on bone metabolism and the correlation between changes in bone turnover parameters and serum cytokine levels. For this purpose, 38 postmenopausal subjects with hypercholesterolemia (>240 mg/dl), not on osteoporosis treatment, were studied. Simvastatin was started at a dose of 20 mg daily and continued for 3 months. Six patients were excluded from the study during the follow-up period. Pre- and post-treatment samples were analyzed for bone alkaline phosphatase (BAP) and osteocalcin (OCL), as markers of bone formation; for carboxyterminal telopeptide of collagen I (CTX), as a marker of bone resorption; and for interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) cytokine levels. Total cholesterol level was decreased from 262.1 +/- 30.9 to 210.2 +/- 35.6 mg/dl after simvastatin treatment (P < 0.0001). While no significant change was observed in serum CTX level, BAP and OCL levels were significantly increased (from 120.8 +/- 56.6 to 149.5 +/- 57.6 IU/l [P = 0.008], and from 20.8 +/- 12.6 to 34.7 +/- 18.4 microg/l [P = 0.015], respectively). In the analysis of cytokines, while no significant change was observed in IL-6 levels, the TNF-alpha level was found to be significantly decreased after simvastatin treatment (from 77.9 +/- 31.6 pg/ml to 23.5 +/- 12.6 pg/ml [P = 0.021]). Individual changes in TNF-alpha levels showed a moderate negative correlation with the individual changes in BAP and OCL levels (r = -0.550 [P = 0.001], and r = -0.497 [P = 0.004], respectively). In conclusion; 20-mg daily simvastatin treatment for 3 months significantly increased BAP and OCL levels (markers of bone formation) in hypercholesterolemic postmenopausal subjects, without affecting bone resorption. These findings support the idea that simvastatin has an anabolic effect on bone formation. Additionally, the presence of a negative correlation between TNF-alpha levels and the anabolic bone parameters suggests that a cytokine-lowering effect of simvastatin may also be involved in the remodeling process and could exert some additive beneficial effect on bone metabolism.