P4608BET-inhibition with Apabetalone in Post-ACS Patients with Diabetes: Design and Baseline Characteristics of the BETonMACE trial

Background

Diabetes (DM) is associated with increased risk of macro/microvascular disease and cognitive decline. Inflammation and vascular calcification may be contributing factors. Bromodomain and extraterminal (BET) proteins coordinate gene transcription and modify the transcriptional response to hyperglycemia, and inflammation. Apabetalone competitively and selectively inhibits binding between BET proteins and acetyl-lysine marks on histone tails: normalizing transcriptional profiles to physiological levels; reducing in vitro alkaline phosphatase (ALP) transcription and in vivo plasma ALP in a dose-dependent manner. Phase 2 trials with apabetalone show improved renal function in the chronic kidney disease (CKD) subgroups. Furthermore, treatment showed a 55% reduction in CVD events with more pronounced benefit among patients with DM, low HDL-cholesterol (HDL-C) and high sensitivity C-reactive protein (hsCRP).

Methods

The double-blind, placebo controlled phase 3 BETonMACE trial is testing the hypothesis that apabetalone 100 mg b.i.d., added to standard care, reduces major adverse cardiovascular events (MACE: CV death, non-fatal myocardial infarction or stroke) in patients with DM, acute coronary syndrome (ACS) within the preceding 7–90 days, low HDL-C (<40 mg/dL in men; <45 mg/dL in women), and estimated glomerular filtration rate (eGFR) >30 mL/min/1.7m2. The trial will continue until at least 250 MACE, providing 80% power to detect a 30% reduction. Secondary endpoints include changes in eGFR in patients with baseline eGFR 30 to <60 mL/min/1.7m2, inflammatory markers, lipids, and ALP. In addition the Montreal Cognition Assessment (MoCA) test was performed in patients ≥70 years of age at baseline and annually.

Results

Enrollment of 2425 patients across 13 countries and 195 centers is now complete. Baseline characteristics [median (IQR)] include LDL-C 65.0 (36) mg/dL, HDL-C 33.0 (7) mg/dL, HbA1c 7.3 (2.3) %, hsCRP 2.8 (4.9) mg/L, mean blood pressure 129/76 mmHg, and CKD in 266 patients (10.8%). Background care was based on guideline recommendations. Diabetes medications include metformin (79%), insulin (36%), sulfonylureas (28%), DPP4 inhibitors (11%), SGLT2 inhibitors (9.7%) and GLP1 receptor agonists (0.3%). The CKD subpopulation vs. total population differed significantly from the whole population with regard to age (71 vs. 62 y. o.), male sex (58% vs. 75%), history of hypertension (46% vs. 88%), history of stroke (1.5% vs. 7.5%), and current smokers (6.1% vs. 13%). In the 70 year and older (n=466, 19%) population 54% (n=243) showed a baseline MoCA score 25 and lower suggesting cognitive impairment.

Summary

The BETonMACE trial is testing the hypothesis that selective BET-inhibition with apabetalone, added to established, evidence-based treatment, reduces MACE in high-risk patients with DM, recent ACS, and low HDL-C. The study will also assess apabetalone's effect on renal function and cognition.

Clinically Feasible Microstructural MRI to Quantify Cervical Spinal Cord Tissue Injury Using DTI, MT, and T2*-Weighted Imaging: Assessment of Normative Data and Reliability

BACKGROUND AND PURPOSE

DTI, magnetization transfer, T2*-weighted imaging, and cross-sectional area can quantify aspects of spinal cord microstructure. However, clinical adoption remains elusive due to complex acquisitions, cumbersome analysis, limited reliability, and wide ranges of normal values. We propose a simple multiparametric protocol with automated analysis and report normative data, analysis of confounding variables, and reliability.

MATERIALS AND METHODS

Forty healthy subjects underwent T2WI, DTI, magnetization transfer, and T2*WI at 3T in <35 minutes using standard hardware and pulse sequences. Cross-sectional area, fractional anisotropy, magnetization transfer ratio, and T2*WI WM/GM signal intensity ratio were calculated. Relationships between MR imaging metrics and age, sex, height, weight, cervical cord length, and rostrocaudal level were analyzed. Test-retest coefficient of variation measured reliability in 24 DTI, 17 magnetization transfer, and 16 T2*WI datasets. DTI with and without cardiac triggering was compared in 10 subjects.

RESULTS

T2*WI WM/GM showed lower intersubject coefficient of variation (3.5%) compared with magnetization transfer ratio (5.8%), fractional anisotropy (6.0%), and cross-sectional area (12.2%). Linear correction of cross-sectional area with cervical cord length, fractional anisotropy with age, and magnetization transfer ratio with age and height led to decreased coefficients of variation (4.8%, 5.4%, and 10.2%, respectively). Acceptable reliability was achieved for all metrics/levels (test-retest coefficient of variation < 5%), with T2*WI WM/GM comparing favorably with fractional anisotropy and magnetization transfer ratio. DTI with and without cardiac triggering showed no significant differences for fractional anisotropy and test-retest coefficient of variation.

CONCLUSIONS

Reliable multiparametric assessment of spinal cord microstructure is possible by using clinically suitable methods. These results establish normalization procedures and pave the way for clinical studies, with the potential for improving diagnostics, objectively monitoring disease progression, and predicting outcomes in spinal pathologies.

A Novel MRI Biomarker of Spinal Cord White Matter Injury: T2*-Weighted White Matter to Gray Matter Signal Intensity Ratio

BACKGROUND AND PURPOSE

T2*-weighted imaging provides sharp contrast between spinal cord GM and WM, allowing their segmentation and cross-sectional area measurement. Injured WM demonstrates T2*WI hyperintensity but requires normalization for quantitative use. We introduce T2*WI WM/GM signal-intensity ratio and compare it against cross-sectional area, the DTI metric fractional anisotropy, and magnetization transfer ratio in degenerative cervical myelopathy.

MATERIALS AND METHODS

Fifty-eight patients with degenerative cervical myelopathy and 40 healthy subjects underwent 3T MR imaging, covering C1-C7. Metrics were automatically extracted at maximally compressed and uncompressed rostral/caudal levels. Normalized metrics were compared with t tests, area under the curve, and logistic regression. Relationships with clinical measures were analyzed by using Pearson correlation and multiple linear regression.

RESULTS

The maximally compressed level cross-sectional area demonstrated superior differences (P = 1 × 10^-13), diagnostic accuracy (area under the curve = 0.890), and univariate correlation with the modified Japanese Orthopedic Association score (0.66). T2*WI WM/GM showed strong differences (rostral: P = 8 × 10^-7; maximally compressed level: P = 1 × 10^-11; caudal: P = 1 × 10^-4), correlations (modified Japanese Orthopedic Association score; rostral: -0.52; maximally compressed level: -0.59; caudal: -0.36), and diagnostic accuracy (rostral: 0.775; maximally compressed level: 0.860; caudal: 0.721), outperforming fractional anisotropy and magnetization transfer ratio in most comparisons and cross-sectional area at rostral/caudal levels. Rostral T2*WI WM/GM showed the strongest correlations with focal motor (-0.45) and sensory (-0.49) deficits and was the strongest independent predictor of the modified Japanese Orthopedic Association score (P = .01) and diagnosis (P = .02) in multivariate models (R² = 0.59, P = 8 × 10^-13; area under the curve = 0.954, respectively).

CONCLUSIONS

T2*WI WM/GM shows promise as a novel biomarker of WM injury. It detects damage in compressed and uncompressed regions and contributes substantially to multivariate models for diagnosis and correlation with impairment. Our multiparametric approach overcomes limitations of individual measures, having the potential to improve diagnostics, monitor progression, and predict outcomes.

Adult outcomes of three newborns with a combined weight of 1100 grams

OBJECTIVE

To present the short- and long-term (20 years) growth and developmental outcomes of four micropremies (birth weight of less than 500 grams).

METHOD

Retrospective review of medical records and prospective assessment/interview with patients and their families.

RESULTS

One infant was lost at long-term follow-up. The other three showed a quite satisfactory health status and life style in early adulthood.

CONCLUSIONS

Despite extreme low birth weight (less than 500 grams) normal outcomes are possible. In the case of micropremies, gestational age appears to be of greater importance than birth weight as well as female gender in the decision-making process regarding initiation of resuscitation.

Biological control of ticks

Ticks have numerous natural enemies, but only a few species have been evaluated as tick biocontrol agents (BCAs). Some laboratory results suggest that several bacteria are pathogenic to ticks, but their mode of action and their potential value as biocontrol agents remain to be determined. The most promising entomopathogenic fungi appear to be Metarhizium anisopliae and Beauveria bassiana, strains of which are already commercially available for the control of some pests. Development of effective formulations is critical for tick management. Entomopathogenic nematodes that are pathogenic to ticks can potentially control ticks, but improved formulations and selection of novel nematode strains are needed. Parasitoid wasps of the genus Ixodiphagus do not typically control ticks under natural conditions, but inundative releases show potential value. Most predators of ticks are generalists, with a limited potential for tick management (one possible exception is oxpeckers in Africa). Biological control is likely to play a substantial role in future IPM programmes for ticks because of the diversity of taxa that show high potential as tick BCAs. Considerable research is required to select appropriate strains, develop them as BCAs, establish their effectiveness, and devise production strategies to bring them to practical use.

Biologic studies of chimeras of highly and moderately virulent molecular clones of simian immunodeficiency virus SIVsmPBj suggest a critical role for envelope in acute AIDS virus pathogenesis

Previous studies identified three molecular clones of the acutely pathogenic SIVsmPBj strain that varied in terms of relative in vivo pathogenicity. One clone, SIVsmPBj6.6, reproducibly induced a rapidly fatal disease in pigtailed macaques. In contrast, a highly related clone (SIVsmPBj6.9) was only minimally pathogenic in macaques. PBj6.6 and PBj6.9 shared a tyrosine substitution at position 17 in the Nef protein that is a major determinant of virulence but differed at one residue in Vpx (C89R), three residues within the envelope (D119G, R871G, G872R), and a single residue in Nef (F252L). SIVsmPBj6.9 was less efficient in inducing proliferation of resting macaque peripheral blood mononuclear cells in vitro than SIVsmPBj6.6 and exhibited a marked reduction in infectivity relative to SIVsmPBj6.6. Chimeric viruses for each of these variable residues were constructed, and their biologic properties were compared to those of the parental strains. Differences in Vpx and Nef did not alter the basic biologic phenotype of the chimeras. However, the D119G substitution in the envelope of SIVsmPBj6.9 was associated with a marked reduction in the infectivity of this virus relative to SIVsmPBj6.6. An associated processing defect in gp160 of SIVsmPBj6.9 and chimeras expressing the D119G substitution suggests that a reduction in virion envelope incorporation is the mechanistic basis for reduced virion infectivity. In vivo studies revealed that substitution of the PBj6.9 amino acid into PBj6.6 (D119) abrogated the pathogenicity of this previously pathogenic virus. Introduction of the PBj6.9 G119, however, did not confer full virulence to the parental PBj6.9 virus, implicating one or all of the other four substitutions in the virulence of SIVsmPBj6.6.

Long-term cholesterol-lowering effects of psyllium as an adjunct to diet therapy in the treatment of hypercholesterolemia

BACKGROUND

Hypercholesterolemia is a major risk factor for coronary heart disease and nutrition management is the initial therapeutic approach.

OBJECTIVE

This multicenter study evaluated the long-term effectiveness of psyllium husk fiber as an adjunct to diet in the treatment of persons with primary hypercholesterolemia.

DESIGN

Men and women with hypercholesterolemia were recruited. After following an American Heart Association Step I diet for 8 wk (dietary adaptation phase), eligible subjects with serum LDL-cholesterol concentrations between 3.36 and 4.91 mmol/L were randomly assigned to receive either 5.1 g psyllium or a cellulose placebo twice daily for 26 wk while continuing diet therapy.

RESULTS

Serum total and LDL-cholesterol concentrations were 4.7% and 6.7% lower in the psyllium group than in the placebo group after 24-26 wk (P < 0.001). Other outcome measures did not differ significantly between groups.

CONCLUSIONS

Treatment with 5.1 g psyllium twice daily produces significant net reductions in serum total and LDL-cholesterol concentrations in men and women with primary hypercholesterolemia. Psyllium therapy is an effective adjunct to diet therapy and may provide an alternative to drug therapy for some patients.

A review of metabolic and cardiovascular effects of oral antidiabetic agents: beyond glucose-level lowering

It has become evident that cardiovascular disease is the major cause of morbidity and mortality in type 2 diabetes mellitus. This raises the possibility that glucose lowering agents with other nonglucose-lowering effects, might have added benefits. In this review, we focus on the metabolic and cardiovascular effects of oral antidiabetic agents that go beyond glucose-level lowering. Such effects include lipid modifying actions, antithrombotic and profibrinolytic activities, and direct action at the level of the vessel wall to improve endothelial function or prevent smooth muscle hyperplasia. These additional activities, particularly those seen with the newer oral antidiabetic agents, hold the promise of reducing cardiovascular complications beyond that achievable by glucose lowering alone.

Translocation efficiency, susceptibility to proteasomal degradation, and lipid responsiveness of apolipoprotein B are determined by the presence of beta sheet domains

Apolipoprotein (apo) B100 is an atypical secretory protein in that its translocation across the endoplasmic reticulum membrane is inefficient, resulting in the partial translocation and exposure of apoB100 on the cytoplasmic surface of the endoplasmic reticulum. Cytosolic exposure leads to the association of nascent apoB with heat shock protein 70 and to its predisposition to ubiquitination and proteasomal degradation. The basis for the inefficient translocation of apoB100 remains unclear and controversial. To test the hypothesis that beta sheet domains present in apoB100 contribute to its inefficient translocation, we created human apoB chimeric constructs apoB13,16 and apoB13,13,16, which contain amino-terminal alpha globular domains but no beta sheet domains, and apoB13,16,beta, which has an amphipathic beta sheet domain of apoB100 inserted into apoB13,16. These constructs, along with carboxyl-terminal truncations of apoB100, apoB34 and apoB42, were used to transfect HepG2 and Chinese hamster ovary cells. In contrast to the lack of effect of proteinase K on apoB13,16 and apoB13,13,16, the levels of apoB34, apoB42, and apoB13,16,beta were decreased by 70-85% after proteinase K-induced proteolysis in both HepG2 and Chinese hamster ovary cells. Either oleic acid or proteasomal inhibitors (N-acetyl-leucinyl-leucinyl-norleucinal and lactacystin) significantly increased the cell levels of apoB13,16,beta, apoB34, apoB42, and full-length apoB100 but had no effect on the cell levels of apoB13,16 and apoB13,13,16. When HepG2 cells were incubated with a microsomal triglyceride transfer protein inhibitor, the cellular levels of apoB13,16,beta, apoB34, and apoB42 were decreased by 70-80%, whereas the levels of apoB13,16 and apoB13,13,16 were unaffected. The effects of microsomal triglyceride transfer protein inhibition were reversed by lactacystin. Our results clearly demonstrate that the translocation efficiency, susceptibility to proteasomal degradation, and lipid responsiveness of apoB were determined by the presence of a lipid binding beta sheet domain. It is possible that beta sheet domains may at least transiently facilitate the interaction of apoB with the lipid bilayer surrounding the translocation channel.

Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with Alzheimer's disease

The apolipoprotein-epsilon 4 allele increases the risk of Alzheimer's disease (AD), but cerebral deposition of beta-amyloid with age, a genetic mutation, or head injury may contribute to the pathogenesis of this disease. We examined the risks of AD associated with traumatic head injury and apolipoprotein-epsilon 4 in 236 community-dwelling elderly persons. A 10-fold increase in the risk of AD was associated with both apolipoprotein-epsilon 4 and a history of traumatic head injury, compared with a two-fold increase in risk with apolipoprotein-epsilon 4 alone. Head injury in the absence of an apolipoprotein-epsilon 4 allele did not increase risk. These data imply that the biological effects of head injury may increase the risk of AD, but only through a synergistic relationship with apolipoprotein-epsilon 4.

Low-dose combined therapy with fluvastatin and cholestyramine in hyperlipidemic patients

OBJECTIVE

To compare the low-density lipoprotein (LDL) cholesterol-lowering efficacy of low-dose combinations of cholestyramine and fluvastatin.

DESIGN

Randomized, double-blind, parallel group, placebo-controlled trial with a 24-week double-blind treatment period divided into three phases.

SETTING

Office-based clinics.

PATIENTS

Hypercholesterolemic, with LDL cholesterol of 4.14 mmol/L or greater (> or = 160 mg/dL) and plasma triglycerides of 3.39 mmol/L or less (< or = 300 mg/dL). Four hundred sixty patients were screened; 224 patients were randomized into a double-blind treatment period; 203 completed the study; 6 dropped out because of adverse events.

INTERVENTION

Patients were treated with 10 mg or 20 mg of fluvastatin alone, 8 g or 16 g of cholestyramine alone, or combinations of these fluvastatin and cholestyramine dosages (six treatment groups).

MEASUREMENTS

Changes in lipid variables, particularly LDL cholesterol.

RESULTS

The 10-mg and 20-mg fluvastatin monotherapy groups showed considerable reductions in LDL cholesterol initially (-20.1% [SD, 8.8%] and -20.2% [SD, 10.1%], respectively); these reductions were maintained. Reductions in LDL cholesterol that resulted from the addition of cholestyramine, 8 g/d, to 10 mg of fluvastatin and 20 mg of fluvastatin were greater than those observed with monotherapy (10-mg fluvastatin--[10-mg fluvastatin plus cholestyramine], 9.1%; 95% CI, 3.8% to 14.4%) and 20-mg fluvastatin--[20-mg fluvastatin plus cholestyramine], 11.6%; CI, 6.5% to 16.8%). The increase in cholestyramine dose to 16 g/d in the three combination groups provided only a modest additional response.

CONCLUSIONS

Low-density lipoprotein cholesterol reductions of about 25% to 30% can be achieved with low-dose combination therapy with fluvastatin and cholestyramine. The addition of low-dose resin appears to produce greater overall cholesterol reduction than does a simple doubling of the fluvastatin dosage. The low-dose combination treatment was highly successful in achieving the goals of the National Cholesterol Education Program guidelines.

The apolipoprotein epsilon 4 allele in patients with Alzheimer's disease

Apolipoprotein E (APO-E) binds to the beta-amyloid peptide and is present in senile neuritic plaques in Alzheimer's disease (AD). The epsilon 4 isoform of APO-E has been associated with both sporadic and familial late-onset AD, implying a causal role. Among patients and control subjects similar in age, gender, and ethnic group from the New York City community of Washington Heights-Inwood, we found that the odds ratio (OR) for AD associated with homozygosity for APO-epsilon 4 was 17.9 (95% confidence interval [CI], 4.6-69.8) and that associated with heterozygosity for APO-epsilon 4 was 4.2 (95% CI, 1.8-9.5) compared with persons with other APO-E genotypes. The association was stronger among patients with sporadic disease (OR = 10.3; 95% CI, 3.4-31.1) than among those with a family history of dementia in a first-degree relative (OR = 0.9; 95% CI, 0.1-13.5). The association between APO-epsilon 4 and AD did not differ according to age at onset (< 65 vs > or = 65), but appeared to vary across the 3 ethnic groups investigated (black, Hispanic, and white). Our data confirm the association between AD and APO-epsilon 4 and support the hypothesis that the APO-epsilon 4 allele either confers genetic susceptibility to AD or may be in linkage disequilibrium with another susceptibility locus. Ethnic variability in the allelic frequency of APO-epsilon 4 in the elderly warrants further investigation.

Protection of iodine-125 brachytherapy brain injury in the rat with the 21-aminosteroid U-74389F

Radiation protection was studied in a rat brachytherapy brain injury model. Radiation lesions were produced by stereotactic placement of high-activity iodine-125 seeds on the frontal lobe of F-344 rats. A minimum dose of 80 Gy was delivered to a 5.5-mm-radius volume. Radiation damage was evaluated 24 h after removal of the seeds by T1-weighted gadolinium-enhanced magnetic resonance imaging on a 1.5-T unit. Computerized three-dimensional reconstruction of the lesions seen on magnetic resonance imaging was performed to calculate the volume of radiation injury. Two experiments were performed with rats of different weights (mean, 300 g; mean, 180 g). All animals underwent surgical placement of an indwelling internal jugular catheter before brachytherapy. Treated animals received the 21-aminosteroid U-74389F 5 mg/kg intravenously every 6 hours during the implant and for 24 hours after the removal of the iodine-125 seed. Control animals were administered vehicle only. In both experiments, a statistically significant reduction in volume of radiation damage was observed in the U-74389F-treated group compared with the control group.

Rapid heating: critical theoretical assessment of thermal gradients found in hyperthermia treatments

There is increasing evidence that many hyperthermia failures are closely related to the large variability of temperatures found in the treatment field. These are linked to thermal gradients near the treatment boundary, vascular perfusion differences, localized cooling, and poor distribution of energy deposition in the tissues. One way of reducing the temperature gradients is to replace traditional heating treatments of 30-60 min by a rapid heating technique, in which the treatment time is a few seconds combined with higher treatment temperatures. The purpose of this paper is to model potential advantages of using various rapid heating protocols, and to compare them with traditional treatments. Theoretical models (in agreement with clinical treatments) suggest that traditional hyperthermia treatments often do not produce the necessary temperature homogeneity needed to kill the last malignant cells in the tumour due to cooler regions in the field. The simulations presented in this paper suggest that much shorter treatment times (1-10 s) should give significant improvements in the treatment field for both the temperature homogeneity and equivalent thermal doses.

Serum IgG and IgA antibodies specific to Epstein-Barr virus capsid antigen in a longitudinal study of human immunodeficiency virus infection and disease progression in homosexual men

A longitudinal study of serum IgG and IgA antibody titers to Epstein-Barr virus (EBV) viral capsid antigen (VCA) was carried out in 218 homosexual men at various stages of human immunodeficiency virus (HIV) infection. The serum samples tested were obtained from the following groups: 24 HIV seroconverters, 41 persistently HIV-seropositive asymptomatic individuals, 22 seropositives who developed AIDS-related complex (ARC), 29 HIV seropositives who developed lymphadenopathy syndrome (LAS), 35 HIV seronegatives with LAS, 36 asymptomatic HIV seronegatives, and 31 AIDS patients. Blind-tested samples were titrated for IgG and IgA EBV-VCA antibodies by immunoperoxidase assay (IPA). Cross-sectional analysis indicated that all HIV-seropositive subjects exhibited significantly elevated EBV IgG and IgA antibody titers compared with HIV-seronegative subjects. The proportions with EBV-VCA IgA antibodies at a titer of greater than or equal to 128 rose during the course of HIV infection and progression of the disease: 8% in HIV seronegatives, 11% in HIV seronegatives with LAS, 25% in HIV seronegatives prior to HIV seroconversion, 44% in asymptomatic HIV seropositives, 34% in LAS, 50% in ARC, and 58% in AIDS patients. An increase in EBV-VCA IgG and IgA titers was detected following HIV seroconversion and in samples obtained 6 months before disease progression to LAS. These data suggest the possible involvement of EBV in the natural history of HIV infection and disease progression. The possibility that EBV-VCA IgA antibody levels would be of value in prediction of progression of HIV-related illness is discussed.

Chenodeoxycholic acid normalizes elevated lipoprotein secretion and catabolism in cerebrotendinous xanthomatosis

Cerebrotendinous xanthomatosis (CTX) is a rare inherited lipid storage disease caused by a defect in bile acid synthesis in which cholesterol and its product cholestanol are deposited in neurological and vascular tissue. Therapy with chenodeoxycholic acid but not with the 7 beta-epimeric ursodeoxycholic acid is usually successful. In an untreated patient, total and low density lipoprotein (LDL) cholesterol were found to be low (134 +/- 11 and 78 +/- 8 mg/dl, respectively). The production rate (PR) and fractional catabolic rate (FCR) of very low density (VLDL) apolipoprotein B (apoB) were, however, both markedly increased (34.7 mg/kg per day and 13.7 pools/day, respectively vs. 15.1 +/- 5.0 mg/kg per day and 6.2 +/- 3.8 pools/day in controls) while the PR and FCR of LDL apoB were moderately elevated (16.3 mg/kg per day and 0.65 pools/day, respectively vs. 12.9 +/- 1.2 mg/kg per day and 0.52 +/- 0.10 pools/day in controls). After 1 month of 750 mg/day of chenodeoxycholic acid, the FCR and PR of both VLDL and LDL apoB became normal while total plasma cholesterol increased significantly to 145 +/- 18 mg/dl. In a second patient who had been receiving 750 mg/day of chenodeoxycholic acid for 6 months lipoprotein kinetics were normal. These parameters did not change when the subject was switched to 750 mg/day ursodeoxycholic acid. We postulate that cholesterol biosynthesis in CTX is derepressed by a diminished hepatic pool of chenodeoxycholic acid and that the elevated secretion of apoB is a response to the increased rate of cholesterol production.

High-density lipoprotein cholesterol is reduced in patients with sarcoidosis

PURPOSE

Sarcoidosis is a disease in which the proliferation of monocyte-macrophage-derived cells is observed. In other diseases characterized by expansion of the monocyte-macrophage system, such as Gaucher's disease and myeloid metaplasia, abnormalities of lipoprotein metabolism have been demonstrated. To determine whether similar abnormalities in lipoprotein cholesterol concentrations could be identified in patients with sarcoidosis, we studied total cholesterol, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol as well as triglyceride levels in 52 patients with biopsy-proven sarcoidosis.

PATIENTS AND METHODS

Patients had no other medical disorders and were not being treated with corticosteroids or antimalarial agents. Blood samples were collected by venipuncture after an overnight fast. Plasma total cholesterol and triglyceride levels were measured using enzymatic techniques. Lipoprotein cholesterol was quantified by lipoprotein fractionation. HDL cholesterol was measured as cholesterol remaining in the supernatant after precipitation of LDL and very-low-density lipoprotein from whole plasma by the heparin-maganese chloride method. Computation was used to determine the level of LDL cholesterol.

RESULTS

We found significantly reduced levels of total cholesterol (183.9 +/- 27.6 versus 194.3 +/- 16.5 mg/dl, mean +/- SD, p = 0.021) and HDL cholesterol (41.2 +/- 13.0 versus 51.9 +/- 6.1 mg/dl, p = 0.0001) in sarcoid patients versus an age-, sex-, and race-matched reference group. Differences were not observed in triglyceride or LDL cholesterol levels (p greater than 0.05).

CONCLUSION

These findings are similar to those observed in the myeloproliferative diseases, Gaucher's disease, and rheumatoid arthritis and suggest a functional role for monocytes-macrophages in the regulation of serum lipoprotein cholesterol levels.

Hypocholesterolemia and acute myelogenous leukemia. Association between disease activity and plasma low-density lipoprotein cholesterol concentrations

Plasma total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol concentrations were determined in 32 patients admitted with either acute nonlymphocytic leukemia or chronic myelogenous leukemia in blast crisis. Measurements were repeated in 15 of these individuals during a leukopenic period induced by chemotherapy and in 6 of the latter group when they had achieved remission. Initial plasma total, LDL, and HDL cholesterol levels in 15 male (111.9 +/- 27.9; 53.7 +/- 10.4; 23.7 +/- 22.5 mg/dl) and 17 female (124.0 +/- 42.0; 68.6 +/- 32.0; 29.4 +/- 13.9 mg/dl) patients were markedly reduced compared with age and sex-matched control values (all P less than 0.01). Remission in six subjects was associated with significant increases in total cholesterol (162.0 +/- 61.0 vs. 111.5 +/- 47.9 mg/dl; P less than 0.02) and LDL cholesterol (106.8 +/- 51.2 vs. 43.5 +/- 31.3 mg/dl; P less than 0.05) compared with their baseline values. Chemotherapy-induced leukopenia was associated with inconsistant changes in plasma cholesterol levels although LDL cholesterol increased in all patients who subsequently achieved remission. LDL cholesterol levels fell dramatically in two patients who relapsed. These results indicate that LDL cholesterol concentrations may be of value in assessing disease activity in individuals with acute myelogenous leukemia.

Very low-density lipoprotein metabolism in an unusual case of lipoatrophic diabetes

Complete acquired lipoatrophic diabetes (LD) is characterized by nonketotic insulin-resistant diabetes, elevated very low-density lipoprotein (VLDL) triglyceride (TG) levels, and absent subcutaneous fat. We studied a young child in whom LD atypically developed after the onset of type 1 diabetes mellitus. On uncontrolled home diet the patient had triglyceride levels over 1,000 mg/dL on multiple occasions. In order to demonstrate the effects of caloric and dietary-fat restriction on VLDL metabolism, 3H-glycerol and autologous 125I-VLDL were used to quantitate the turnover of VLDL-TG and VLDL-apolipoprotein B (apo B) during two periods of caloric restriction. Consumption of a 900-kcal 40-g fat diet resulted in a plasma triglyceride level of 1383 mg/dL (ten-fold elevation). This hypertriglyceridemia was associated with markedly increased production rates of both VLDL-TG (73.7 mg/kg/h) and VLDL-apo B (126.9 mg/kg/d). Consumption of a 900-kcal 25-g fat diet resulted in a plasma TG level of 663 mg/dL. This reduction in plasma TG was associated with a 40% decrease in VLDL-TG production rate (PR) (45.1 mg/kg/h). There was no change in the production rate (PR) of VLDL-apo B. The hypertriglyceridemia in this patient was due to marked over production of VLDL. Furthermore, the studies demonstrate: (1) the independent benefits of caloric and dietary-fat restriction in the treatment of LD, and (2) that fat restriction lowered plasma triglyceride by its effect on the VLDL-TG production rate.

Diet and the decrease of coronary heart disease

Total plasma cholesterol is a powerful predictor of death related to coronary heart disease (CHD). Strong evidence indicates that reducing the plasma cholesterol level results in in a decrease in the expected incidence of CHD. The decline in the death rate from CHD in the U.S. population over the past 2 decades has occurred simultaneously with a reduction in the consumption of cholesterol and saturated fat and a dramatic increase in the use of unsaturated vegetable oils. Over the same period, the mean cholesterol level has decreased at least 5%. This finding explains up to one-third of the decline in CHD mortality observed since 1968.

Reduced plasma concentrations of total, low density lipoprotein and high density lipoprotein cholesterol in patients with Gaucher type I disease

Plasma lipid and serum apoprotein concentrations were determined in twenty-nine individuals with Gaucher type I disease. Plasma total cholesterol, low density lipoprotein (LDL) cholesterol and high density lipoprotein (HDL) cholesterol were all significantly reduced in the patients with Gaucher disease compared to a group of matched control subjects. Total, LDL and HDL cholesterol were lower in males than in females with Gaucher disease. These sex differences appeared to be inversely correlated with the severity of disease manifestations which were greater in the males. Serum levels of apoprotein-B and apoprotein-AI, the major structural apoproteins of LDL and HDL, respectively, were decreased in the subjects with Gaucher disease. Thus, the reductions in LDL and HDL cholesterol were associated with reduced numbers of lipoprotein particles in plasma. In contrast, apoprotein-E, a protein which is secreted by several tissues, including activated macrophages and which may mediate hepatic catabolism of lipoproteins, was elevated in the patients. Since macrophages may also catabolize lipoproteins, Gaucher disease may serve as a model for the effect of activated macrophages upon human lipoprotein metabolism.

Evidence that the penton base of adenovirus is involved in potentiation of toxicity of Pseudomonas exotoxin conjugated to epidermal growth factor

When KB cells are incubated for 1 h with human adenovirus type 2 or type 5 (1 microgram/ml) and a conjugate of epidermal growth factor and Pseudomonas exotoxin (EGF-PE), protein synthesis is inhibited by 80 to 90%. Under these conditions, neither adenovirus nor EGF-PE alone has any effect on host protein synthesis. Thus, adenovirus enhances the toxicity of EGF-PE. A number of antibodies to intact virus and capsid components were tested for their ability to block the enhancing activity and virus uptake. At appropriate dilutions, antibodies prepared against intact virus and penton base blocked the enhancing activity without affecting virus uptake. Antibodies against hexon and fiber blocked virus uptake and enhancing activity in parallel. These studies suggest that the penton base is important in lysis of the vesicles which contain adenovirus and EGF-PE, and this base allows virus and toxin to enter the cytoplasm.

The effect of chronic hypocholesterolemia in myeloproliferative disease on the distribution of plasma and erythrocyte tocopherol

The presence of hypocholesterolemia and increased erythrocyte lipid peroxidation susceptibility in myeloproliferative disorders raised the possibility of coexistent tocopherol deficiency. Plasma and red blood cell (RBC) alpha-tocopherol, beta- + gamma-tocopherol, and free cholesterol were determined simultaneously by high performance liquid chromatography in 22 patients and 26 controls. Plasma alpha-tocopherol was correlated most highly with plasma free cholesterol and secondarily with RBC alpha-tocopherol in both groups. Plasma-free cholesterol and alpha-tocopherol were significantly reduced in myeloproliferative disease, although the ratio between the two remained normal. Erythrocyte tocopherol and free cholesterol concentrations were normal in myeloproliferative disease. High relative retention of tocopherol by erythrocytes was most pronounced in patients with the lowest plasma alpha-tocopherol and free cholesterol levels. The normal RBC tocopherol levels in these patients with chronic hypocholesterolemia indicate that the observed increase in RBC peroxidation susceptibility is not explainable by a deficiency of RBC vitamin E.

Increased erythrocyte susceptibility to lipid peroxidation in myeloproliferative disorders

The recognition of abnormal lipoprotein metabolism that produces chronic hypocholesterolemia in myeloproliferative disorders and the known influence of altered plasma lipid levels on erythrocyte membranes prompted a study of erythrocyte susceptibility to lipid peroxidation in myeloproliferative disease. Malonyldialdehyde generation during an oxidant challenge of erythrocyte suspensions of standardized hemoglobin concentration with H2O2 was significantly greater in 32 patients with myeloproliferative disease than in 47 hematologically normal subjects. The myeloproliferative disease group had significantly lower plasma total, HDL-, and LDL-cholesterol, erythrocyte indices, and erythrocyte deformability, and higher reticulocyte counts and serum lactic dehydrogenase. In the myeloproliferative disease group, mean corpuscular hemoglobin concentration, reticulocyte count, and erythrocyte count were significant variables in accounting for the observed variation in peroxidation susceptibility. Erythrocytes of patients with myeloproliferative disease had elevated concentrations of reduced glutathione, normal glutathione stability, and normal alpha-tocopherol content. These studies demonstrate increased susceptibility to oxidative damage in myeloproliferative disease despite normal or increased concentrations of the major antioxidant compounds of the erythrocyte. The presence of reticulocytosis, elevated serum lactic dehydrogenase, and decreased erythrocyte deformability suggests that lipid peroxidation susceptibility is associated with in vivo hemolysis and may contribute to the anemia that complicates myeloproliferative disease.

Increased catabolism of native and cyclohexanedione-modified low density lipoprotein in subjects with myeloproliferative diseases

We previously demonstrated reduced levels of low density lipoprotein (LDL) cholesterol in association with increased total fractional catabolic rates (FCR( of LDL apoprotein B (apo B) in individuals with myeloproliferative diseases (MPD). The removal of LDL from plasma and interstitial fluid is mediated via receptor and nonreceptor pathways. We attempted to quantitate LDL catabolism via each of these pathways in subjects with MPD and control subjects. The total FCR of LDL apo B was measured using radiolabeled native LDL. The FCR of radiolabeled cyclohexanedione-modified LDL (CHD-LDL) was used to assess the nonreceptor-mediated catabolism of LDL. Total FCR (mean +/- SD) was elevated in MPD vs controls (0.78 +/- 0.32 vs 0.45 +/- 0.11, p less than 0.01). CHD-LDL FCR was also increased in MPD vs controls (0.62 +/- 0.53 vs 0.23 +/- 0.04, p less than 0.01). Studies of the plasma decay of radiolabeled native and CHD-LDL preparations after their injection into cynomolgus monkeys indicated that CHD-LDL preparations from MPD and controls were removed at the same rates in those primates and that all CHD-LDL preparations were catabolized more slowly than the native LDL preparations. Studies in vitro indicated that CHD modification of LDL significantly reduced the rate of degradation of this lipoprotein by a specific high-affinity receptor pathway in normal human monocyte-derived macrophages and cultured human fibroblasts. We conclude that the catabolism of both native and CHD-LDL apo B is increased in subjects with MPD. If CHD-LDL is a valid tracer of nonreceptor-mediated removal of native LDL in individuals with MPD, our results indicate that the reduced LDL cholesterol concentrations demonstrated in these subjects are associated with increased nonreceptor-mediated catabolism of LDL apo B. At this time, both neoplastic cells and activated monocyte-macrophages appear to be likely sites of these abnormalities.

Hypocholesterolemia as a manifestation of disease activity in chronic myelocytic leukemia

A patient with chronic myelocytic leukemia and hypocholesterolemia displayed marked fluctuations in plasma cholesterol in response to several therapeutic maneuvers. During chemotherapy there was a reciprocal relation between low density lipoprotein (LDL) cholesterol levels and the degree of leukocytosis and splenomegaly. LDL cholesterol increased after splenectomy, but continued to cycle inversely with the leukocyte count. Receptor-mediated degradation of 125I-labeled LDL (125I-LDL) by mononuclear cells in vitro also showed cyclical changes which were unrelated to the number of immature myeloid cells in the population or the level of plasma cholesterol. 125I-LDL degradation rate was normal or slightly increased during relapse and after remission was achieved, but was greatly increased when tested during periods of remission induction. This patient illustrates that significant changes in plasma total and LDL cholesterol occur in chronic myelocytic leukemia in association with alterations in proliferative state. Tumor load, the presence of an enlarged spleen, and changes in lipid metabolism of circulating cells all appear to contribute to the reduction in LDL cholesterol levels.

Very low density lipoprotein metabolism in non-ketotic diabetes mellitus: effect of dietary restriction

We have measured the turnover of very low density lipoprotein (VLDL) triglyceride as well as plasma glucose, insulin and non-esterified fatty acid levels in nine mildly obese non-ketotic, insulinopenic diabetic subjects before and during an energy restricted diet. During the baseline period, subjects were hypertriglyceridaemic, hyperglycaemic and insulinopenic. During dietary restriction (mean weight loss: 2.3 +/- 0.4 kg) plasma triglyceride fell from 8.4 +/- 3.0 to 3.4 +/- 0.89 mmol/l (mean +/- SEM: p less than 0.05), and plasma glucose fell from 13.9 +/- 1.7 to 9.8 +/- 1.4 mmol/l (p less than 0.01). Neither fasting plasma insulin nor the insulin response to an oral glucose load changed. Plasma non-esterified fatty acid concentrations remained constant as well. During the baseline period, the transport rate of VLDL-triglyceride in the diabetic subjects was more than twice that in an age-weighted matched control group (27.4 +/- 2.9 versus 12.1 +/- 0.8 mg/kg ideal body weight per h). The fractional catabolic rates were similar in the two groups (0.20 +/- 0.05 versus 0.21 +/- 0.02/h). During energy restriction of the diabetic subjects, the VLDL-triglyceride transport rate fell to 17.4 +/- 2.9 mg/kg ideal body weight per h (p less than 0.05 versus baseline) while the fractional catabolic rate remained constant at 0.21 +/- 0.06/h (NS versus baseline). These data indicate that the major abnormality in triglyceride metabolism in these non-ketotic, insulinopenic diabetic patients was over-production of VLDL-triglyceride.

Metabolism of cholesterol and plasma triglycerides in nonketotic diabetes mellitus

The metabolism of cholesterol and plasma triglycerides (TG) was studied in 14 diabetic men: these patients did not have marked obesity nor did they develop ketoacidosis without insulin. Before insulin therapy, measurements were made of (1) plasma lipoproteins, (2) postheparin lipolytic enzymes, (3) turnover to TG in very-low-density lipoproteins (VLDL) and chylomicrons, (4) cholesterol balance, and (5) biliary lipids. After baseline measurements, the patients were treated with enough long-acting insulin to maintain their fasting plasma glucose in the range of 100--125 mg/dl. When plasma glucose and lipid levels reached a new steady state, all of the above measurements were repeated. Before insulin, most patients had fasting hypertriglyceridemia. This was due mainly to overproduction of VLDL-TG. Insulin therapy lowered both synthesis and concentrations of VLDL-TG to near normal. Also, patients with normotriglyceridemia, both before and during insulin therapy, had essentially normal clearance of chylomicrons. Those with high fasting TG had delayed clearance of chylomicrons, but clearance returned to normal in most with insulin therapy. Postheparin lipolytic enzymes were not decreased. Before insulin, synthesis rates of cholesterol and bile acids usually were greater than normal, and bile commonly was supersaturated with cholesterol. During insulin therapy, synthesis of both cholesterol and bile acids remained elevated, possibly because of imperfect control of hyperglycemia. Furthermore, saturation of bile with cholesterol was accentuated by insulin therapy.

Increased low-density-lipoprotein catabolism in myeloproliferative disorders

Hypocholesterolemia reported in patients with myeloproliferative disorders prompted our investigation of lipoprotein metabolism in these patients. The production and fractional catabolic rates of very-low-density lipoprotein (VLDL) apoprotein-B were measured using 131I-VLDL; those of VLDL triglyceride, using 3H-glycerol; and those of low-density lipoprotein (LDL) apoprotein-B, using 125I-LDL. Plasma total and LDL cholesterol levels (mean +/- SD) were significantly reduced in seven patients with myeloproliferative diseases, compared to five normal subjects (93.1 +/- 20.3 mg/dL versus 166.8 +/- 24.6 mg/dL and 50.3 +/- 14.8 mg/dL versus 107 +/- 20.8 mg/dL, respectively). The production rates of VLDL apoprotein-B and VLDL triglyceride were normal in the patients. The fractional catabolic rate of LDL apoprotein-B was increased in the patients with myeloproliferative diseases (0.89 +/- 0.32/d versus 0.52 +/- 0.10/d; p less than 0.05); this increased rate was associated with reduced plasma LDL apoprotein-B levels (41.7 +/- 7.1 mg/dL versus 57.0 +/- 11.3 mg/dL; p less than 0.05) despite normal or elevated LDL apoprotein-B production (16.7 +/- 5.3 mg/kg body weight . d versus 12.9 +/- 1.2 mg/kg body weight . d). The site (or sites) of increased LDL catabolism in these hypocholesterolemic patients with myeloproliferative disorders is under investigation.

Lipoprotein metabolism in nonresponders to increased dietary cholesterol

We have studied the effect of increased dietary cholesterol on production and degradation of plasma very low density lipoproteins and low density lipoproteins. We studied five unselected normal volunteers who were on weight-maintaining diets consisting of 45% carbohydrate, 40% fat, and 15% protein with a ratio of polyunsaturated to saturated fat of 0.4. Cholesterol content was 150 mg/1000 kcal in Period A and 500 mg/1000 kcal in Period B. Subjects were fed each diet for 4 to 5 weeks. The turnover of apoproteins B in very low density and low density lipoproteins and of triglyceride in very low density lipoproteins were measured during the last 2 weeks of each study period using 131I-labeled very low density lipoproteins and 125I-labeled low density lipoproteins and 2-3H-glycerol, respectively. There was no significant change in plasma total cholesterol or triglycerides or in low density lipoprotein cholesterol levels during the high cholesterol versus the low cholesterol diet. Similarly, high cholesterol intake had no effect on the rate of production or clearance of apo B in very low density and low density lipoproteins or of triglyceride in very low density lipoproteins. These data indicate that the flux of very low density lipoproteins does not change in nonresponders to high cholesterol diets.

Characterization of hypocholesterolemia in myeloproliferative disease. Relation to disease manifestations and activity

Characterization of the hypocholesterolemia observed in polycythemia vera and agnogenic myeloid metaplasia revealed significant reductions in plasma total cholesterol, low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol in an age- and sex-matched comparison with the Framingham population. Men with myeloproliferative disease also had significantly lower total and LDL cholesterol levels than did those with relative or secondary polycythemia. LDL and HDL cholesterol were significantly correlated, suggesting a generalized disturbance of cholesterol metabolism, unexplained by nutritional status. Evaluation of the relationship among hematic cell proliferation, degree of myeloid metaplasia and hypocholesterolemia by multiple regression analysis revealed that spleen size was the variable of most significance in explaining the variation in plasma total, LDL and HDL cholesterol levels. Uncontrolled disease activity was accompanied by a decline in LDL cholesterol levels. Splenectomy or control of proliferation with chemotherapy or splenic irradiation reversed this abnormality. Levels of plasma total and lipoprotein cholesterol provide information that may be of value in diagnosis and assessment of myeloproliferative disease activity.

Effect of insulin therapy on insulin resistance in type II diabetic subjects. Evidence for heterogeneity

Insulin resistance has been demonstrated previously in both glucose-intolerant and untreated type II diabetics. Although the former group had hyperinsulinemia in the fasting state and after an oral glucose load, the hyperglycemic type II subjects were relatively insulin deficient after carbohydrate ingestion. In an attempt to define the role that insulin deficiency might have played in the pathophysiology of insulin resistance in this latter group, we measured the steadystate plasma glucose level (SSPG) during a constant infusion of glucose (6 mg/kg/min) and insulin (80 mU/min) in 15 nonobese insulin-deficient type II diabetics before and after insulin replacement therapy. Hepatic glucose output (HGO) and plasma clearance of glucose (PCG) during these studies were also determined using an infusion of 3-3H-glucose.

Before insulin treatment, 13 of 15 subjects had SSPG levels above the range reported in normal subjects. Two type II patients appeared to be normally sensitive to insulin. Although all subjects were more sensitive to insulin after 1–8 wk of insulin therapy, they could be clearly divided into two groups. Thus, five patients were now normally sensitive to insulin (SSPG:75 ± 5.3 mg/dl) while 10 patients were still significantly resistant (SSPG: 227±11.3 mg/dl). HGO during the infusion studies was high in the resistant group pretreatment and did not change posttreatment (3.54 ± 0.32 vs. 3.14 ± 0.78 mg/kg/min). HGO was lower before insulin therapy and decreased by &gt; 50% after therapy in the sensitive group (1.93 ± 0.07 vs. 0.71 ± 0.32 mg/kg/min). PCG determinations revealed a similar pattern of response. Retrospective analysis of the two groups revealed no significant differences in their baseline characteristics. Fasting plasma glucose and hemoglobin A1c levels also did not differ between the two groups before or after insulin therapy.

These results indicate that heterogeneity exists among subjects with type II diabetes mellitus. One-third of the subjects studied appear to have only insulin deficiency as the basis of their diabetes, while two-thirds seem to have an underlying resistance to insulin that is not corrected by insulin therapy.

Metabolism of plasma triglycerides in hypothyroidism and hyperthyroidism in man

Studies on plasma triglycerides (TG) were performed in 10 nonobese and 16 obese patients with hypothyroidism and in 13 with hyperthyroidism. Nonobese, hypothyroid patients generally had normal levels of TG, but obese patients often had hypertriglyceridemia. In most hypothyroid patients 1-thyroxine treatment lowered plasma TG, and most hyperthyroid patients had low TG. One mechanism whereby thyroid hormones might decrease plasma TG could be to increase lipoprotein lipase (LPL). However, post-heparin LPL was not increased after therapy, nor was it increased in hyperthyroid patients. In contrast, hypothyroid patients had abnormally low levels of post-heparin hepatic triglyceride lipase. In hypothyroid patients without hypertriglyceridemia, clearance of chylomicrons was normal. A few obese, hypothyroid patients with fasting hypertriglyceridemia had low clearance of chylomicrons, which may have been due in part to competition for removal of excess endogenous TG. Thus, no evidence was obtained for a significant abnormality in chylomicron metabolism in hypothyroidism. Nonobese, hypothyroid patients had normal synthesis and clearance of very low density lipoprotein (VLDL)-TG. In contrast, VLDL-TG synthesis was increased in 8 obese, hypothyroid patients, and fractional clearance rates were relatively low compared to obese, euthyroid subjects. In striking contrast, hyperthyroid patients had remarkable facility in clearing VLDL-TG. Thus, TG metabolism is not grossly deranged in hypothyroidism, but thyroid hormones apparently can promote catabolism of VLDL.