A randomized clinical trial of hydroxymethylglutaryl-Coenzyme A reductase inhibition for Acute Lung Injury (The HARP study)

Rationale: There is no effective pharmacological treatment for acute lung injury (ALI). Statins are a potential new therapy because they modify many of the underlying processes important in ALI.

Objectives: To test whether simvastatin improves physiological and biological outcomes in ALI.

Methods: We conducted a randomized, double-blinded, placebo-controlled trial in patients with ALI. Patients received 80 mg simvastatin or placebo until cessation of mechanical ventilation or up to 14 days. Extravascular lung water was measured using thermodilution. Measures of pulmonary and nonpulmonary organ function were assessed daily. Pulmonary and systemic inflammation was assessed by bronchoalveolar lavage fluid and plasma cytokines. Systemic inflammation was also measured by plasma C-reactive protein.

Measurements and Main Results: Sixty patients were recruited. Baseline characteristics, including demographics and severity of illness scores, were similar in both groups. At Day 7, there was no difference in extravascular lung water. By Day 14, the simvastatin-treated group had improvements in nonpulmonary organ dysfunction. Oxygenation and respiratory mechanics improved, although these parameters failed to reach statistical significance. Intensive care unit mortality was 30% in both groups. Simvastatin was well tolerated, with no increase in adverse events. Simvastatin decreased bronchoalveolar lavage IL-8 by 2.5-fold (P = 0.04). Plasma C-reactive protein decreased in both groups but failed to achieve significance in the placebo-treated group.

Conclusions: Treatment with simvastatin appears to be safe and may be associated with an improvement in organ dysfunction in ALI. These clinical effects may be mediated by a reduction in pulmonary and systemic inflammation.

The Crowned Harp: Policing Northern Ireland (reprint 2006, 2010)

The Crowned Harp provides a detailed analysis of policing in Northern Ireland. Tracing its history from 1922, Ellison and Smyth portray the Royal Ulster Constabulary (RUC) as an organisation burdened by its past as a colonial police force. They analyse its perceived close relationship with unionism and why, for many nationalists, the RUC embodied the problem of the legitimacy of Northern Ireland, arguing that decisions made on the organisation, composition and ideology of policing in the early years of the state had consequences which went beyond the everyday practice of policing.

The authors provide an extended discussion of policing after the outbreak of civil unrest in 1969, ask why policing was cast in a paramilitary mould, and look at the use of special constabularies and the way in which the police dealt with social unrest which threatened to break down sectarian divisions. Examining the reorganisations of the RUC in the 1970s and 1980s, Ellison and Smyth focus on the various structural, legal and ideological components, the professionalisation of the force and the development of a coherent, if contradictory, ideology. The analysis of the RUC during this period sheds light on the problematic nature of using the police as a counter insurgency force in a divided society. Perceptions of the police, and the opinions of rank and file members are examined and an assessment is made of the various alternative models of policing, such as community policing and local control. This book offers important lessons about the nature of policing in divided societies.

Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial: study protocol for a randomized controlled trial

Background: Acute lung injury (ALI) is a common devastating clinical syndrome characterized by life-threatening respiratory failure requiring mechanical ventilation and multiple organ failure. There are in vitro, animal studies and pre-clinical data suggesting that statins may be beneficial in ALI. The Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial is a multicenter, prospective, randomized, allocation concealed, double-blind, placebo-controlled clinical trial which aims to test the hypothesis that treatment with simvastatin will improve clinical outcomes in patients with ALI.

Methods/Design: Patients fulfilling the American-European Consensus Conference Definition of ALI will be randomized in a 1: 1 ratio to receive enteral simvastatin 80 mg or placebo once daily for a maximum of 28 days. Allocation to randomized groups will be stratified with respect to hospital of recruitment and vasopressor requirement. Data will be recorded by participating ICUs until hospital discharge, and surviving patients will be followed up by post at 3, 6 and 12 months post randomization. The primary outcome is number of ventilator-free days to day 28. Secondary outcomes are: change in oxygenation index and sequential organ failure assessment score up to day 28, number of non pulmonary organ failure free days to day 28, critical care unit mortality; hospital mortality; 28 day post randomization mortality and 12 month post randomization mortality; health related quality of life at discharge, 3, 6 and 12 months post randomization; length of critical care unit and hospital stay; health service use up to 12 months post-randomization; and safety. A total of 540 patients will be recruited from approximately 35 ICUs in the UK and Ireland. An economic evaluation will be conducted alongside the trial. Plasma and urine samples will be taken up to day 28 to investigate potential mechanisms by which simvastatin might act to improve clinical outcomes.

Superimposition: A composition for harp, saxophone and live electronics

Superimposition is built on a live-scoring system. Computer animated graphics combined with computer generated algorithms produce the score in real time based on preferences input by the composer. Notably, this system introduces a methodology for eliciting complex and coordinated rhythms from instrumentalists through notation generated in real time. This work also incorporates a system for live electronics and live sampling and processing.

"Thought-Tormented Music": Joyce and the Music of the Irish Revival

"In this special issue's opening essay, Martin Dowling devotes almost half of "'Thought-Tormented Music': Joyce and the Music of the Irish Revival" to what he calls "the situation of music in the Irish literary revival." He focuses chiefly on 1904, which was both an intensely productive period for the revival movement and a year chock-full of crucial events and decisions for Joyce. Drawing on the works of Pierre Bourdieu and Jaques Lacan, Dowling explores the revivalists' efforts to "de-anglicize" Irish music, to remove foreign influences that distorted the "pure tradition of Irish song," and to achieve an improbable harmony between the music favoured by the disappearing Anglo-Irish aristocracy and the Irish-speaking peasantry. Inevitably, disputes occurred over what constituted "authentic" Irish music. Factions quarrelled over whether pristine Irish music existed in the Atlantic seaboard or more inland; whether "authentic" songs were sung with or without instrumental accompaniment; and whether the piano, rather than the traditional harp, was a legitimate instrument of accompaniment. Having delineated the historical and theoretical context, Dowling offers a richly detailed analysis of Joyce's story "A Mother." He reveals how almost every element in the story--from the Eire Abu Society to the Antient Concert Rooms, from the conflict between Mrs. Kearney and Hoppy Holohan to the plight of Kathleen Kearney--is charged with meaning by the subtextual conflicts of the revivalists' agenda. Dowling explains also the "authenticity" in Joyce's depiction of vocal performances of "The Lass of Aughrim" in "The Dead" and "The Croppy Boy" in "Sirens," which he calls two "true gems" of authentic Irish music." --Introduction by Charles Rossman and Alan W. Friedman, Guest Editors, pp. 409-410

Simvastatin in the Acute Respiratory Distress Syndrome

Background

Studies in animals and in vitro and phase 2 studies in humans suggest that statins may be beneficial in the treatment of the acute respiratory distress syndrome (ARDS). This study tested the hypothesis that treatment with simvastatin would improve clinical outcomes in patients with ARDS.

Methods

In this multicenter, double-blind clinical trial, we randomly assigned (in a 1:1 ratio) patients with an onset of ARDS within the previous 48 hours to receive enteral simvastatin at a dose of 80 mg or placebo once daily for a maximum of 28 days. The primary outcome was the number of ventilator-free days to day 28. Secondary outcomes included the number of days free of nonpulmonary organ failure to day 28, mortality at 28 days, and safety.

Results

The study recruited 540 patients, with 259 patients assigned to simvastatin and 281 to placebo. The groups were well matched with respect to demographic and baseline physiological variables. There was no significant difference between the study groups in the mean (±SD) number of ventilator-free days (12.6±9.9 with simvastatin and 11.5±10.4 with placebo, P=0.21) or days free of nonpulmonary organ failure (19.4±11.1 and 17.8±11.7, respectively; P=0.11) or in mortality at 28 days (22.0% and 26.8%, respectively; P=0.23). There was no significant difference between the two groups in the incidence of serious adverse events related to the study drug.

Conclusions

Simvastatin therapy, although safe and associated with minimal adverse effects, did not improve clinical outcomes in patients with ARDS. (Funded by the U.K. National Institute for Health Research Efficacy and Mechanism Evaluation Programme and others; HARP-2 Current Controlled Trials number, ISRCTN88244364.)

Characteristics of Corticospinal Projections to the Intrinsic Hand Muscles in Skilled Harpists.

The process of learning to play a musical instrument necessarily alters the functional organisation of the cortical motor areas that are involved in generating the required movements. In the case of the harp, the demands placed on the motor system are quite specific. During performance, all digits with the sole exception of the little finger are used to pluck the strings. With a view to elucidating the impact of having acquired this highly specialized musical skill on the characteristics of corticospinal projections to the intrinsic hand muscles, focal transcranial magnetic stimulation (TMS) was used to elicit motor evoked potentials (MEPs) in three muscles (of the left hand): abductor pollicis brevis (APB); first dorsal interosseous (FDI); and abductor digiti minimi (ADM) in seven harpists. Seven non-musicians served as controls. With respect to the FDI muscle–which moves the index finger, the harpists exhibited reliably larger MEP amplitudes than those in the control group. In contrast, MEPs evoked in the ADM muscle–which activates the little finger, were smaller in the harpists than in the non-musicians. The locations on the scalp over which magnetic stimulation elicited discriminable responses in ADM also differed between the harpists and the non-musicians. This specific pattern of variation in the excitability of corticospinal projections to these intrinsic hand muscles exhibited by harpists is in accordance with the idiosyncratic functional demands that are imposed in playing this instrument.