Down-regulation of pituitary receptors for luteinizing hormone-releasing hormone (LH-RH) in rats by LH-RH antagonist Cetrorelix.

Antagonists of luteinizing hormone-releasing hormone (LH-RH), unlike the LH-RH agonists, suppress gonadotropins and sex steroid secretion immediately after administration, without initial stimulatory effects. [Ac-D-Nal(2)1,D-Ph(4Cl)2,D-Pal(3)3,D-Cit6,D-Ala10]LH-R H (SB-75; Cetrorelix) is a modern, potent antagonistic analog of LH-RH. In this study, the binding characteristics of receptors for LH-RH in membrane fractions from rat anterior pituitaries were investigated after a single injection of Cetrorelix at a dose of 100 microg per rat. To determine whether the treatment with Cetrorelix can affect the concentration of measurable LH-RH binding sites, we applied an in vitro method to desaturate LH-RH receptors by chaotropic agents such as manganous chloride (MnCl2) and ammonium thiocyanate (NH4SCN). Our results show that the percentages of occupied LH-RH receptors at 1, 3, and 6 h after administration of Cetrorelix were approximately 28%, 14%, and 10%, respectively, of total receptors. At later time intervals, we could not detect occupied LH-RH binding sites. Ligand competition assays, following in vitro desaturation, demonstrated that rat pituitary LH-RH receptors were significantly (P < 0.01) down-regulated for at least 72 h after administration of Cetrorelix. The lowest receptor concentration was found 3-6 h after Cetrorelix treatment and a recovery in receptor number began within approximately 24 h. The down-regulation of LH-RH binding sites induced by Cetrorelix was accompanied by serum LH and testosterone suppression. Higher LH-RH receptor concentrations coincided with elevated serum hormone levels at later time intervals. Our results indicate that administration of LH-RH antagonist Cetrorelix produces a marked down-regulation of pituitary receptors for LH-RH and not merely an occupancy of binding sites.

Midcycle administration of a progesterone synthesis inhibitor prevents ovulation in primates.

Progesterone receptors appear in granuloma cells of preovulatory follicles after the midcycle gonadotropin surge, suggesting important local actions of progesterone during ovulation in primates. Steroid reduction and replacement during the gonadotropin surge in macaques was used to evaluate the role of progesterone in the ovulatory process. Animals received gonadotropins to induce development of multiple preovulatory follicles, followed by human chorionic gonadotropin (hCG) administration (day 0) to promote oocyte (nuclear) maturation, ovulation, and follicular luteinization. On days 0-2, animals received no further treatment; a steroid synthesis inhibitor, trilostane (TRL); TRL + R5020; or TRL + dihydrotestosterone propionate (DHT). On day 3, ovulation was confirmed by counting ovulation sites and collecting oviductal oocytes. The meiotic status of oviductal and remaining follicular oocytes was evaluated. Peak serum estradiol levels, the total number of large follicles, and baseline serum progesterone levels at the time of hCG administration were similar in all animals. Ovulation sites and oviductal oocytes were routinely observed in controls. Ovulation was abolished in TRL. Progestin, but not androgen, replacement restored ovulation. Relative to controls, progesterone production was impaired for the first 6 days post-hCG in TRL, TRL + R5020, and TRL + DHT. Thereafter, progesterone remained low in TRL but recovered to control levels with progestin and androgen replacement. Similar percentages of mature (metaphase II) oocytes were collected among groups. Thus, steroid reduction during the gonadotropin surge inhibited ovulation and luteinization, but not reinitiation of oocyte meiotic maturation, in the primate follicle. The data are consistent with a local receptor-mediated role for progesterone in the ovulatory process.

Modulation of pair bonding in female prairie voles (Microtus ochrogaster) by corticosterone.

Glucocorticoid levels in animals may respond to and influence the development of social attachments. This hypothesis was tested in prairie voles (Microtus ochrogaster), monogamous rodents that form long-term heterosexual pair bonds. In socially naive female prairie voles, cohabitation with an unfamiliar male resulted in a dramatic decline in serum corticosterone levels. When corticosterone levels were reduced via adrenalectomy, females developed partner preferences after 1 h of cohabitation, while sham-operated and untreated females required 3 h or more of nonsexual cohabitation to establish a partner preference. In adrenalectomized and intact females, exogenous injections of corticosterone, given prior to social exposure, prevented the development of preferences for the cohabitating male. Although corticosterone inhibited the development of partner preferences, it did not interfere with the expression of previously established social preferences. These results suggest that social stimuli can modulate adrenal activity and that adrenal activity, in turn, is capable of influencing the formation of adult social preferences in female prairie voles. The involvement of the adrenal axis in the formation of partner preferences and the subsequent development of pair bonds provides a mechanism through which environmental and social factors may influence social organization in this species.

Appearance of insulin-like growth factor mRNA in the liver and pyloric ceca of a teleost in response to exogenous growth hormone.

Augmentation of vertebrate growth by growth hormone (GH) is primarily due to its regulation of insulin-like growth factor I (IGF I) and IGF II levels. To characterize the effect of GH on the levels of IGF I and IGF II mRNA in a teleost, 10 micrograms of bovine GH (bGH) per g of body weight was administered to juvenile rainbow trout (Oncorhynchus mykiss) through i.p. injection. The levels of IGF I and IGF II mRNA were determined simultaneously, by using RNase protection assays, in the liver, pyloric ceca, kidney, and gill at 0, 1, 3, 6, 12, 24, 48, and 72 hr after injection. In the liver, IGF I mRNA levels were significantly elevated at 6 and 12 hr (approximately 2- to 3-fold, P < or = 0.01), while IGF II mRNA levels were significantly elevated at 3 and 6 hr (approximately 3-fold, P < or = 0.01). In the pyloric ceca, IGF II mRNA levels were significantly elevated at 12, 24, and 48 hr (approximately 3-fold, P < or = 0.01), while IGF I mRNA was below the limits of assay accuracy. GH-dependent IGF mRNA appearance was not detected in the gill and kidney. Serum bGH levels, determined by using a radioimmunoassay, were significantly elevated at 3 and 6 hr (P < 0.005). In primary hepatocyte culture, IGF I and IGF II mRNA levels increased in a bGH dose-dependent fashion, with ED50 values of approximately 45 and approximately 6 ng of bGH per ml, respectively. The GH-dependent appearance of IGF II mRNA in the liver and pyloric ceca suggests important roles for this peptide hormone exclusive of IGF I.

Otimização dos valores de referência da 17OH-progesterona neonatal de acordo com o peso ao nascimento no programa de triagem neonatal da APAE DE SÃO PAULO

Introdução: A Hiperplasia Adrenal Congênita por deficiência da 21-hidroxilase (HAC) é uma doença com mortalidade neonatal elevada sendo elegível para programas públicos de Triagem Neonatal (TN). A HAC é causada por mutações no gene CYP21A2, as quais acarretam diferentes comprometimentos da atividade enzimática e resultam em espectro amplo de manifestações clínicas. Apesar da eficiência da TN para diagnosticar os casos graves, a taxa elevada de resultados falso-positivos (RFP), principalmente relacionados à prematuridade, é um dos maiores problemas. Porém, resultados falso-negativos também podem ocorrer em coletas antes de 24 horas de vida. No Brasil, a coleta da amostra neonatal difere entre os municípios, podendo ser no terceiro dia de vida como após. Objetivo: Avaliar se os valores da 17OH-progesterona neonatal (N17OHP) das coletas no terceiro dia de vida diferem significativamente das coletas a partir do quarto dia. Determinar qual percentil (99,5 ou 99,8) pode ser utilizado como valor de corte para a N17OHP, de acordo com o peso ao nascimento e tempo de vida na coleta, a fim de que proporcione taxa menor de RFP. Métodos: Foi avaliada, retrospectivamente, a N17OHP de 271.810 recém-nascidos (Rns) de acordo com o tempo de vida na coleta (G1: 48 - = 72h) e peso ao nascimento (P1: <= 1.500g, P2: 1.501-2.000g, P3: 2.001-2.500g e P4: >= 2.500g), pelo método imunofluorimétrico. Testes com resultados alterados foram confirmados no soro por Espectrometria de Massas em Tandem - LC-MS/MS. Rns afetados e/ou assintomáticos e com valores persistentemente elevados de 17OHP sérica foram submetidos ao estudo molécular, sequenciamento do gene CYP21A2. Resultados: os valores da N17OHP no grupo G1 foram significativamente menores do que em G2 em todos os grupos de peso (p < 0.001). A taxa de RFP em G1 e G2 foi de 0,2% para o percentil 99,8 e de 0,5% para o percentil 99,5 em ambos os grupos. O percentil 99,8 da N17OHP foi o melhor valor de corte para distinguir os Rns não afetados dos afetados, cujos valores são: G1 (P1: 120; P2: 71; P3: 39 e P4: 20 ng /mL) e em G2 (P1: 173; P2: 90; P3: 66 e P4: 25 ng/mL). Vinte e seis Rns do grupo G1 apresentaram a forma perdedora de sal (PS) (13H e 13M), nestes a N17OHP variou de 31 a 524 ng/mL e vinte Rns no grupo G2 (8H e 12M), nestes a N17OHP variou de 53 a 736 ng/mL. Para ambos os grupos foram encontrados três Rns com a forma virilizante simples (1H e 2M) e os valores da N17OHP variaram de 36 a 51 ng/mL. Resultados falso-negativos não foram relatados. O valor preditivo positivo (VPP) no teste do papel filtro foi de 5,6% e 14,1% nos grupos G1 e G2, respectivamente, ao se utilizar o percentil 99,8, e de 2,3% e 7% nos grupos G1 e G2 ao se utilizar o percentil 99,5. Dentre os casos com TN alterada (RFP), 29 deles também apresentaram 17OHP sérica elevada quando dosada por LC-MS/MS. Os casos assintomáticos foram acompanhados até normalização da 17OHP sérica e/ou submetidos ao estudo molecular, que identificou dois Rns com genótipo que prediz a forma não clássica. Conclusão: a melhor estratégia para otimização do diagnóstico da HAC na triagem neonatal é se padronizar valores de corte da N17OHP em dois grupos de acordo com o tempo de vida na coleta (antes e depois de 72 horas), subdivididos em quatro grupos de peso. A utilização dos valores de corte do percentil 99,8 se mantém eficaz no diagnóstico da HAC-21OH na triagem neonatal, reduzindo de forma significativa a taxa de RFP, sem perda do diagnóstico da forma PS

PGC-1 alfa como regulador inflamatório na esteato-hepatite não-alcoólica

A doença hepática gordurosa não-alcoólica (NAFLD, do inglês) é a manifestação clínica hepática da síndrome metabólica, cuja incidência aumenta consideravelmente em todo o mundo. A NAFLD pode progredir para um estado de esteatohepatite não-alcoólica (NASH, do inglês), caracterizado por inflamação hepatocelular, com ou sem fibrose. Dados na literatura mostram que o coativador-1 alfa do receptor ativado por proliferadores de peroxissoma gama (PGC-1alfa), além de estar envolvido em diversos processos metabólicos, representa uma estratégia terapêutica promissora na modulação da inflamação. Neste projeto investigamos as alterações inflamatórias no fígado induzida por dieta hiperlipídica e o papel do PGC-1alfa nesse processo. Camundongos C57black/6 receberam dieta hiperlipídica contendo 30% de gordura por 10 semanas. O peso dos animais foi avaliado semanalmente. Após a eutanásia, o tecido adiposo intra-abdominal (retroperitoneal e periepididimal) foi coletado e pesado. Analisamos o perfil glicêmico e lipídico sérico e expressão de genes envolvidos no metabolismo glicêmico e lipídico. Avaliou-se também o aspecto histológico e a inflamação do tecido hepático por quantificação das citocinas IL-6, TNF-alfa e IL-1beta. A dieta rica em gordura conduziu a um aumento dos depósitos de gordura intra-abdominal, hiperglicemia e hiperlipidemia. Os animais também apresentavam esteatohepatite, com aumento de citocinas pró-inflamatórias e diminuição na expressão de PGC-1alfa no tecido hepático. O envolvimento do PGC-1alfa na produção de mediadores inflamatórios por hepatócitos foi avaliado em células HepG2 utilizando RNA de interferência (RNAi). O knockdown da expressão de PGC-1alfa causou aumento na expressão e liberação de IL-6 em hepatócitos via aumento na fosforilação de IkBalfa e consequente ativação do NFkB. Portanto, nossos dados mostram que o PGC-1alfa inibe a produção de mediadores inflamatórios (IL-6) em hepatócitos, e fornecem novas evidências das conexões existentes entre as vias metabólicas e imunes

Efeitos do transporte e do tempo de espera no bem-estar e na qualidade de carne de cordeiros

Com este estudo objetivou-se avaliar os níveis de estresse e a qualidade de carne de cordeiros mestiços Santa Inês x Dorper, submetidos a transporte de percurso curto (duas horas) e longo (seis horas) e em dois períodos de espera pré-abate (12 ou 24 horas). Foram utilizados 32 cordeiros com 127 ± 7 dias de idade e 30,4 ± 2,1 kg de peso vivo. Antes de serem submetidos aos períodos de transporte, os animais estavam alocados em baias coletivas e receberam ração concentrada (farelo de soja e milho, calcário calcítico e núcleo com monensina), bagaço úmido de citros e capim Napier (Pennisetum purpureum) e água ad libitum. Foram realizadas avaliações de reatividade dos animais no momento do embarque, desembarque e durante a contenção dos animais para as colheitas de sangue, urina e temperatura ocular por termografia infravermelho. Durante o período de espera pré-abate, realizou-se a colheita de dados comportamentais dos animais. Foram avaliadas as concentrações de cortisol no soro, na urina e as concentrações de haptoglobina no soro nos períodos que antecederam a insensibilização, assim como no momento do abate. Os animais apresentaram baixa reatividade durante todos os manejos. Houve diferença significativa no comportamento dos cordeiros durante os períodos de espera (P < 0,05) que durante as 12 horas apresentaram frequência de comportamentos que indicaram bem-estar favorável, enquanto que o período de transporte não afetou (P > 0,05). Os níveis de cortisol no soro mantiveram-se semelhantes da saída dos animais para o transporte até o final do período de espera (P > 0,05), enquanto houve oscilação dessas concentrações no cortisol na urina (P < 0,05), com pico no desembarque dos animais de duas horas de transporte e diminuição ao final do período de descanso. Os níveis de haptoglobina mantiveram-se semelhantes da colheita realizada antes do transporte, no embarque e no desembarque (P > 0,05) e diminuíram no final do período de espera pré-abate (P < 0,05). A temperatura ocular elevou-se no embarque e no desembarque dos animais, com diminuição da temperatura ao final do período de espera (P < 0,05). No momento do abate, foi observado aumento das concentrações de haptoglobina (P < 0,05), enquanto não houve alteração nas concentrações de cortisol no soro (P > 0,05). Animais que permaneceram por 24 horas de espera pré-abate apresentaram maior força de cisalhamento e menor luminosidade (L*) e intensidade de amarelo (b*). As variáveis comportamentais foram pouco afetadas pelos períodos de transporte e de espera pré-abate, porém o período de 12 horas de espera favoreceu a qualidade da carne

Captores del fósforo: preferencias de los pacientes en hemodiálisis y su repercusión sobre el cumplimiento del tratamiento y el control del fósforo

Introducción: En la actualidad disponemos de un amplio abanico de captores del fósforo (CF), pero sabemos poco acerca de las preferencias de los pacientes y de su repercusión sobre el cumplimiento del tratamiento y el control de los niveles de fósforo. Objetivo: Estudiar las preferencias y creencias de los pacientes respecto a los CF, y su influencia sobre el cumplimiento del tratamiento y el control de los niveles de fósforo. Pacientes y métodos: Estudio observacional transversal. Se incluyeron 121 pacientes que respondieron un cuestionario genérico de cumplimiento del tratamiento (SMAQ) y a un cuestionario específico sobre cumplimiento del tratamiento con CF, tipo de CF preferido y razones de dicha preferencia. Todos los pacientes entrevistados habían probado dos o tres CF. Las consecuencias de la falta de cumplimiento del tratamiento con CF se estimaron indirectamente analizando los valores promedio de fósforo sérico. Resultados: El 40% de los pacientes era incumplidor según el cuestionario SMAQ; se encontró una asociación estadísticamente significativa entre la falta de cumplimiento en general y no alcanzar el objetivo de fósforo sérico promedio <5,5 mg/dl (OR = 4,8; IC 95%, 1,0-6,6; p = 0,02). El 21,4% de los pacientes reconocía un incumplimiento específico para los CF; estos pacientes presentaban una mayor probabilidad de tener cifras medias de fósforo >5,5 mg/dl (OR = 4,7; IC 95%, 1,1-6,5; p = 0,03). Un 43,8% de los pacientes no refirió tener preferencias entre los diferentes tipos de CF; para el resto de pacientes, el CF preferido fue Royen®, seguido de Fosrenol®, Renagel® y Pepsamar®. Las razones expresadas para el desagrado con el Renagel® fueron las siguientes: incomodidad en la toma por su gran tamaño (28,8%), necesidad de tomar muchos comprimidos y gran consumo de agua (57,7%) e intolerancia gástrica (13,3%). En el caso del Fosrenol®: incómodo de tomar (72,7%) e intolerancia gástrica (27,2%); para el Pepsamar®: mal sabor (54,5%) e intolerancia gástrica (45,4%). Sólo al 9,4% no le gustaba el Royen®. Al analizar los conocimientos de los pacientes respecto a la utilidad de los CF, un 42% sabía que servían para controlar el fósforo; un 52% no lo sabía y un 6% tenía ideas equivocadas. En cuanto a su importancia: un 47% no conocía por qué son importantes; un 2% tenía ideas erróneas; un 9% creía que era beneficioso para la salud; un 11% creía que era bueno «porque lo dice el medico»; un 26% porque controla el fósforo y un 5% lo relacionaba con el hueso. Ningún paciente relacionó los CF con la enfermedad cardiovascular. Un 24,4% no se llevaba los CF cuando salía fuera de casa o estaba con los amigos; eran pacientes más jóvenes a quienes se les habían prescrito un mayor número de comprimidos de CF y que presentaban un mayor riesgo de no cumplir el objetivo de fósforo (OR = 10,5; IC 95%, —1,8 a —16,4; p <0,001). El porcentaje de pacientes a quienes no les gustaba el CF prescrito fue del 54,5%; dichos pacientes presentaban un mayor riesgo de tener niveles séricos de fósforo >5,5 mg/dl (OR = 13.3; IC 95%, 1,1-1,5; p = 0,0001). Paradójicamente, los pacientes que no cumplían con el tratamiento demostraban un mejor conocimiento de su uso (OR = 17,3; IC 95%, 2,2-10,1; p <0.0001) e importancia (OR = 10,4; IC 95%, 1,5-6,6; p = 0,001). Conclusión: Los pacientes a los que se les habían prescrito CF que no les gustaban tenían un peor control de los niveles de fósforo sérico y se les habían recomendado dosis más altas de los fármacos. El conocimiento de las preferencias de los pacientes acerca de las medicaciones que se les prescriben puede ser un factor esencial para conseguir un mayor cumplimiento del tratamiento y, por ende, lograr mejores resultados en la consecución de los objetivos terapéuticos.

Oleic acid modulates mRNA expression of liver X receptor (LXR) and its target genes ABCA1 and SREBP1c in human neutrophils

Purpose: Regulation of liver X receptors (LXRs) is essential for cholesterol homeostasis and inflammation. The present study was conducted to determine whether oleic acid (OA) could regulate mRNA expression of LXRα and LXRα-regulated genes and to assess the potential promotion of oxidative stress by OA in neutrophils. Methods: Human neutrophils were treated with OA at different doses and LXR target gene expression, oxidative stress production, lipid efflux and inflammation state were analyzed. Results: We describe that mRNA synthesis of both LXRα and ABCA1 (a reverse cholesterol transporter) was induced by OA in human neutrophils. This fatty acid enhanced the effects of LXR ligands on ABCA1 and LXR expression, but it decreased the mRNA levels of sterol regulatory element-binding protein 1c (a transcription factor that regulates the synthesis of triglycerides). Although OA elicited a slight oxidative stress in the short term (15–30 min) in neutrophils, it is unlikely that this is relevant for the modulation of transcription in our experimental conditions, which involve longer incubation time (i.e., 6 h). Of physiological importance is our finding that OA depresses intracellular lipid levels and that markers of inflammation, such as ERK1/2 and p38 mitogen-activated protein kinase phosphorylation, were decreased by OA treatment. In addition, 200 μM OA reduced the migration of human neutrophils, another marker of the inflammatory state. However, OA did not affect lipid peroxidation induced by pro-oxidant agents. Conclusions: This work presents for the first time evidence that human neutrophils are highly sensitive to OA and provides novel data in support of a protective role of this monounsaturated acid against the activation of neutrophils during inflammation.

Mannose-binding lectin gene polymorphism predicts hospital admissions for COPD infections

Infection frequently causes exacerbations of chronic obstructive pulmonary disease (COPD). Mannose-binding lectin (MBL) is a pattern-recognition receptor that assists in clearing microorganisms. Polymorphisms in the MBL2 gene reduce serum MBL levels and are associated with risk of infection. We studied whether the MBL2 codon 54 B allele affected serum MBL levels, admissions for infective exacerbation in COPD and disease susceptibility. Polymorphism frequency was determined by PCR-RFLP in 200 COPD patients and 104 smokers with normal lung function. Serum MBL was measured as mannan-binding activity in a subgroup of 82 stable COPD patients. Frequency of COPD admissions for infective exacerbation was ascertained for a 2-year period. The MBL2 codon 54 B allele reduced serum MBL in COPD patients. In keeping, patients carrying the low MBL-producing B allele had increased risk of admission for infective exacerbation (OR 4.9, P-corrected = 0.011). No association of MBL2 genotype with susceptibility to COPD was detected. In COPD, serum MBL is regulated by polymorphism at codon 54 in its encoding gene. Low MBL-producing genotypes were associated with more frequent admissions to hospital with respiratory infection, suggesting that the MBL2 gene is disease-modifying in COPD. MBL2 genotype should be explored prospectively as a prognostic marker for infection risk in COPD.

Secondary prevention of renal and cardiovascular disease: Results of a renal and cardiovascular treatment program in an Australian aboriginal community

Australian Aborigines are experiencing an epidemic of renal and cardiovascular disease. In late 1995 we introduced a treatment program into the Tiwi community, which has a three- to fivefold increase in death rates and a recent annual incidence of treated ESRD of 2760 per million. Eligible for treatment were people with hypertension, diabetics with micro or overt albuminuria, and all people with overt albuminuria. Treatment centered around use of perindopril (Coversyl, Servier), with other agents added to reach BP goals; attempts to control glucose and lipid levels; and health education. Thirty percent of the adult population, or 267 people, were enrolled, with a mean follow up of 3.39 yr. Clinical parameters were followed every 6 mo, and rates of terminal endpoints were compared with those of 327 historical controls matched for baseline disease severity, followed in the pretreatment program era. There was a dramatic reduction in BP in the treatment group, which was sustained through 3 yr of treatment. Albuminuria and GFR stabilized or improved. Rates of natural deaths were reduced by an estimated 50% (P = 0.012); renal deaths were reduced by 57% (P = 0.038); and nonrenal deaths by 46% (P = 0.085). Survival benefit was suggested at all levels of overt albuminuria, and regardless of diabetes status, baseline BP, or prior administration of angiotensin converting enzyme inhibitors (ACEI). No significant benefit was apparent among people without overt albuminuria, nor among those with GFR less than 60 ml/min. An estimated 13 renal deaths and 10 nonrenal deaths were prevented, with the number-needed-to-treat to avoid one terminal event of only 11.6. Falling deaths and renal failure in the whole community support these estimates. The program was extremely cost-effective. Programs like this should be introduced to all high-risk communities as a matter of urgency.

Optimising care of acute coronary syndromes in three Australian hospitals

Objective. To improve quality of in-hospital care of patients with acute coronary syndromes using a multifaceted quality improvement program. Design. Prospective, before and after study of the effects of quality improvement interventions between October 2000 and August 2002. Quality of care of patients admitted between 1 October 2000 and 16 April 2001 (baseline) was compared with that of those admitted between 15 February 2002 and 31 August 2002 (post-intervention). Setting. Three teaching hospitals in Brisbane, Australia. Study participants. Consecutive patients (n = 1594) admitted to hospital with acute coronary syndrome [mean age 68 years (SD 14 years); 65% males]. Interventions. Clinical guidelines, reminder tools, and educational interventions; 6-monthly performance feedback; pharmacist-mediated patient education program; and facilitation of multidisciplinary review of work practices. Main outcome measures. Changes in key quality indicators relating to timing of electrocardiogram (ECG) and thrombolysis in emergency departments, serum lipid measurement, prescription of adjunctive drugs, and secondary prevention. Results. Comparing post-intervention with baseline patients, increases occurred in the proportions of eligible patients: (i) undergoing timely ECG (70% versus 61%; P = 0.04); (ii) prescribed angiotensin-converting enzyme inhibitors (70% versus 60%; P = 0.002) and lipid-lowering agents (77% versus 68%; P = 0.005); (iii) receiving cardiac counselling in hospital (57% versus 48%; P = 0.009); and (iv) referred to cardiac rehabilitation (17% versus 8%; P < 0.001). Conclusions. Multifaceted approaches can improve care processes for patients hospitalized with acute coronary syndromes. Care processes under direct clinician control changed more quickly than those reliant on complex system factors. Identifying and overcoming organizational impediments to quality improvement deserves greater attention.

Modest weight loss and physical activity in overweight patients with chronic liver disease results in sustained improvements in alanine aminotransferase, fasting insulin, and quality of life

Background and aim: Obesity is a risk factor for progression of fibrosis in chronic liver diseases such as non-alcoholic fatty liver disease and hepatitis C. The aim of this study was to investigate the longer term effect of weight loss on liver biochemistry, serum insulin levels, and quality of life in overweight patients with liver disease and the effect of subsequent weight maintenance or regain. Patients: Thirty one patients completed a 15 month diet and exercise intervention. Results: On completion of the intervention, 21 patients (68%) had achieved and maintained weight loss with a mean reduction of 9.4 (4.0)% body weight. Improvements in serum alanine aminotransferase (ALT) levels were correlated with the amount of weight loss (r=0.35, p=0.04). In patients who maintained weight loss, mean ALT levels at 15 months remained significantly lower than values at enrolment (p=0.004), while in regainers (n=10), mean ALT levels at 15 months were no different to values at enrolment (p=0.79). Improvements in fasting serum insulin levels were also correlated with weight loss (r=0.46, p=0.04), and subsequent weight maintenance sustained this improvement. Quality of life was significantly improved after weight loss. Weight maintainers sustained recommended levels of physical activity and had higher fasting insulin levels (p=0.03) at enrolment than weight regainers. Conclusion: In summary, these findings demonstrate that maintenance of weight loss and exercise in overweight patients with liver disease results in a sustained improvement in liver enzymes, serum insulin levels, and quality of life. Treatment of overweight patients should form an important component of the management of those with chronic liver disease.

Effects of cigarette smoking and exposure to cadmium and lead on phenotypic variability of hepatic CYP2A6 and renal function biomarkers in men

Effects of cigarette smoking and exposure to dietary cadmium (Cd) and lead (Pb) on urinary biomarkers of renal function and phenotypic variability of cytochrome P450 2A6 (CYP2A6) were investigated in a group of 96 healthy Thai men with mean age of 36.7 year (19-57 years). In non-smokers, Cd burden increased with age (r = 0.47, P < 0.001). In current smokers, Cd burden increased with both age (r = 0.45, P = 0.01) and number of cigarettes smoked per day (r = 0.32, P = 0.05). Cd-linked renal tubular dysfunction was seen in both smokers and non-smokers, but Pb-linked glomerular dysfunction was seen in smokers only, possibly due to more recent exposure to high levels of Cd and Pb, as reflected by 30-50% higher serum Cd and Pb levels in smokers than non-smokers (P < 0.05). Exposure to dietary Cd and Pb appeared to be associated with mild tubular dysfunction whereas dietary exposure plus cigarette smoking was associated with tubular plus glomerular dysfunction. Hepatic CYP2A6 activity in non-smokers showed a positive association with Cd burden (adjusted P = 0.38, P = 0.006), but it showed an inverse correlation with Pb (adjusted beta = -0.29, P = 0.003), suggesting opposing effects of Cd and Pb on hepatic CYP2A6 phenotype. In contrast, CYP2A6 activity in current smokers did not correlate with Cd or Pb, but it showed a positive correlation with serum ferritin levels (r = 0.45, P = 0.01). These finding suggest that Pb concentrations in the liver probably were too low to inhibit hepatic synthesis of heme and CYP2A6 and that the concurrent induction of hepatic CYP2A6 and ferritin was probably due to cigarette smoke constituents other than the Cd and Pb. (C) 2004 Elsevier Ireland Ltd. All rights reserved.

Effect of pravastatin on cardiovascular events in people with chronic kidney disease

Background - Limited data describe the cardiovascular benefit of HMG-CoA reductase inhibitors (statins) in people with moderate chronic kidney disease (CKD). The objective of this analysis was to determine whether pravastatin reduced the incidence of cardiovascular events in people with or at high risk for coronary disease and with concomitant moderate CKD. Methods and Results - We analyzed data from the Pravastatin Pooling Project (PPP), a subject-level database combining results from 3 randomized trials of pravastatin ( 40 mg daily) versus placebo. Of 19 700 subjects, 4491 ( 22.8%) had moderate CKD, defined by an estimated glomerular filtration rate of 30 to 59.99 mL/min per 1.73 m(2) body surface area. The primary outcome was time to myocardial infarction, coronary death, or percutaneous/surgical coronary revascularization. Moderate CKD was independently associated with an increased risk of the primary outcome ( adjusted HR 1.26, 95% CI 1.07 to 1.49) compared with those with normal renal function. Among the 4491 subjects with moderate CKD, pravastatin significantly reduced the incidence of the primary outcome ( HR 0.77, 95% CI 0.68 to 0.86), similar to the effect of pravastatin on the primary outcome in subjects with normal kidney function ( HR 0.78, 95% CI 0.65 to 0.94). Pravastatin also appeared to reduce the total mortality rate in those with moderate CKD ( adjusted HR 0.86, 95% CI 0.74 to 1.00, P = 0.045). Conclusions - Pravastatin reduces cardiovascular event rates in people with or at risk for coronary disease and concomitant moderate CKD, many of whom have serum creatinine levels within the normal range. Given the high risk associated with CKD, the absolute benefit that resulted from use of pravastatin was greater than in those with normal renal function.