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Statins are the most effective drugs used worldwide to lower the serum LDL-c by inhibiting the rate-limiting step, HMG-CoA reductase, in cholesterol biosynthesis. Despite its prevalent use, statins are known to increase PCSK9 expression, hindering its efficiency. However, the underlying mechanisms remain elusive. In this study, we have unraveled the pleiotropic effects of statins on hypercholesterolemia via epigenetic regulation of PCSK9. We observed that atorvastatin increases the fold enrichment of H3K4me3 at the promoter of PCSK9 by elevating the expression of the SET1/COMPASS family of proteins like SET1b and MLL1 in HepG2. Additionally, atorvastatin also acetylates H3K9 by increasing the expression of acetyltransferases like CBP and PCAF. Similarly, in mice fed a high-fat diet, atorvastatin showed increased levels of H3K4me3 and H3K9ac in the liver. Furthermore, a pharmacological intervention that inhibits the H3K4me3 and H3K9ac enrichment resulted in the reversal of statin-induced upregulation of PCSK9. Combining statin and OICR-9429 or resveratrol improved the overall uptake of LDL by hepatocytes. Together, these findings suggest that statin induces the colocalization of H3K4me3 and H3K9ac to transcribe PCSK9 actively and that inhibiting these marks reduces PCSK9 expression and ultimately increases hepatocyte LDL uptake. Our study unveils a previously unknown epigenetic mechanism of PCSK9 regulation that may lead to statin resistance or futility in patients and provide a potential therapeutic solution., Competing Interests: Declaration of interest None, (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Multiple myeloma (MM) is a plasma cell dyscrasia characterized by production of abnormal levels of a monoclonal immunoglobulin or plasma cell deposition that leads to end organ destruction. The disease remains incurable despite advances in combination treatments with classes of medications that include proteosome inhibitors, immunomodulating agents, monoclonal antibodies, small molecule inhibitors, alkylating agents, T-cell-based immunotherapies, and others. Checkpoint inhibitors (CKP-I), though showing robust efficacy in solid tumor and lymphoma, have had limited success as single agents in the treatment of MM. Furthermore, early FDA holds on trials involving CKP-I in myeloma led to diminished enrollment and data on its potential use. Nevertheless, clearer understanding of the mechanisms of immune dysregulation and unique bone marrow biology in the pathophysiology of MM have opened the opportunity for future uses of CKP-I in multiple myeloma. Herein we provide a comprehensive review of the immunologic basis of multiple myeloma, preclinical and published data from trials utilizing CKP-I in MM patients, and future targets in CKP-I development that may provide promising opportunities in the treatment of MM., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Chronic wounds suffer from impaired healing due to microbial attack and poor vascular growth. Thermoresponsive hydrogels gained attention in wound dressing owing to their gelation at physiological temperature enabling them to take the shape of asymmetric wounds. The present study delineates the development of thermoresponsive hydrogel (MCK), from hair-derived keratin (K) and methylcellulose (MC) in the presence of sodium sulfate. The gelation temperature (T g ) of this hydrogel is in the range of 30 °C to 33 °C. Protein-polymer interaction leading to thermoreversible sol-gel transition involved in MCK blends has been analyzed and confirmed by FTIR, XRD, and thermal studies. Keratin, has introduced antioxidant properties to the hydrogel imparted cytocompatibility towards human dermal fibroblasts (HDFs) as evidenced by both MTT and live dead assays. In vitro wound healing assessment has been shown by enhanced migration of HDFs in the presence of MCK hydrogel compared to the control. Also, CAM assay and CD31 expression by the Wistar rat model has shown increased blood vessel branching after the implantation of MCK hydrogel. Further, in vivo study, demonstrated MCK efficacy of hydrogel in accelerating full-thickness wounds with minimal scarring in Wistar rats, re-epithelialization, and reinstatement of the epidermal-dermal junction thereby exhibiting clinical relevance for chronic wounds., Competing Interests: Declaration of competing interest There are no conflicts to declare., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aims: Natural Killer T (NKT) cells are reported to be both pro- and anti-atherosclerotic. With this meta-analysis, we evaluated the NKT population and their subsets in regulating the atherosclerotic disease in mice., Main Methods: Eighteen pre-clinical (mice, n = 1276) and 6 clinical observational studies (humans, n = 116) met the eligibility criteria for inclusion. Random effects model was used and standard mean difference (SMD) was calculated for the cell counts and aortic lesion area., Key Findings: Lesion area decreased in the absence of whole NKT cell population (-1.33[95%CI, -2.14, -0.52]), and in the absence of only iNKT subset (-0.66[95%CI, -1.69, 0.37]). However, lesion area increased after over-expression/activation of iNKTs (1.40[95%CI, 0.28, 2.52]). Atherogenic diet (AD) or high fat diet (HFD) increased the number of NKT cells (2.51[95%CI, 1.42, 3.61]), whereas the iNKT cell numbers and iNKT cell-specific gene expression decreased in mice (-2.04[95%CI, -3.34, -0.75]) and atherosclerotic patients (-1.81[95 % CI, -2.89, -0.74])., Significance: Here we show that, NKT and iNKT cells promote atherosclerosis. In general, NKT cell population increases with the progression of the plaque in mice and the numbers of iNKT cells reduce once the disease is established both in mice and humans., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The exploitation of conventional antibiotics in conjunction with the adeptness of microbes has led to the emergence of multi-drug-resistant pathogens. This has posed a severe threat to combating life-threatening infectious diseases. Antimicrobial peptides (AMP), which are considered to be the first line of defense in all living organisms, are being developed for therapeutic use. Herein, we determined the NMR solution structure of Rhesus macaque Myeloid Alpha Defensin-4 (RMAD4), a defensin AMP. Additionally, the distinct modes of membrane perturbation for two structurally dissimilar classes of AMPs was studied using biophysical methods namely, Solid-state 31 P NMR, DSC and cryo-TEM. The cathelicidin - Bovine myeloid antimicrobial peptide (BMAP-28 (1-18)), which adopts a helical conformation, and the defensin RMAD4 peptide that natively folds to form β-sheets appeared to engage differently with the bacterial membrane. The helical BMAP-28 (1-18) peptide initiates lipid segregation and membrane thinning followed by pore formation, while the β-stranded RMAD4 peptide demonstrates fragmentation of the bilayer by the carpet or detergent-like mechanism of action. Molecular dynamics studies sufficiently corroborated these findings. The structure and mechanism of action of the AMPs studied using experimental and computational approaches are believed to help in providing a platform for the rational design of new competent and cost-effective antimicrobial peptides for therapeutic applications., Competing Interests: Declaration of competing interest The authors have no conflict of interest with the content of this article., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The biopharmaceutical industry is undergoing an evolutionary phase with the rise of advanced manufacturing technologies. The regulatory and customer requirements are shifting towards the development of personalized or targeted medicines. With this changing landscape, industry must evaluate the relevance of quality management systems. Over the past two decades, Indian companies have played a significant role in generating access and reducing costs of medicines. The quality management systems that enable the development and manufacturing of biopharmaceuticals require companies to adapt to regulatory requirements of process development, clinical trials, production, and life cycle management. To better understand the status and potential opportunities to enhance the quality management systems of manufacturing biopharmaceuticals, a workshop was organized by United States Pharmacopeia (USP) and Association of Biotechnology Led Enterprises (ABLE). This paper summarizes the recommendations by the panel and participants of the workshop to industry stakeholders, governance bodies, and policymakers. Following points were proposed to strengthen the culture of quality processes in Indian biopharmaceutical industry: i) Inculcating a culture of quality; ii) Effective training programs on quality processes; iii) Focus on quality beyond compliance; iv) Focus on automation and digitization. v) Enhance processes for pharmacovigilance and product life cycle management. vi) Understanding global regulatory processes., (Copyright © 2020 American Pharmacists Association®. All rights reserved.)

Specifying effective analytical techniques and methods can be very challenging when a large number of sample streams need to be analyzed with high frequency. Combining those requirements with the need to monitor multiple components over a wide range of concentrations makes at-line analytical approaches preferred by many analytical scientists. Traditionally, at-line analytical support requires sample preparation and operator time. Recently developed technologies enabled automated sample preparation tools coupled with gas chromatography; thus, eliminating sample preparation steps and increasing productivity. Recently a commercial micro-reactor was introduced that can be combined with a flame ionization detector, providing the ability to quantify components without the need to perform a standard calibration, which saves significant time and materials. In this manuscript, we describe a unique analytical capability that combines automated sample preparation and gas chromatography with flame ionization detection and universal carbon response to provide high flexibility and accuracy when there is minimal information about the unknowns or reference materials are not available. Some of the challenges and performance monitoring techniques for this technology are also discussed in this manuscript., (Copyright © 2019. Published by Elsevier B.V.)

Background: Childhood caries is a major oral and general health problem, particularly in certain populations. In this study, the authors aimed to evaluate the adequacy of the supply of pediatric dentists., Methods: The authors collected baseline practice information from 2,546 pediatric dentists through an online survey (39.1% response rate) in 2017. The authors used a workforce simulation model by using data from the survey and other sources to produce estimates under several scenarios to anticipate future supply and demand for pediatric dentists., Results: If production of new pediatric dentists and use and delivery of oral health care continue at current rates, the pediatric dentist supply will increase by 4,030 full-time equivalent (FTE) dentists by 2030, whereas demand will increase by 140 FTE dentists by 2030. Supply growth was higher under hypothetical scenarios with an increased number of graduates (4,690 FTEs) and delayed retirement (4,320 FTEs). If children who are underserved experience greater access to care or if pediatric dentists provide a larger portion of services for children, demand could grow by 2,100 FTE dentists or by 10,470 FTE dentists, respectively., Conclusions: The study results suggest that the supply of pediatric dentists is growing more rapidly than is the demand. Growth in demand could increase if pediatric dentists captured a larger share of pediatric dental services or if children who are underserved had oral health care use patterns similar to those of the population with fewer access barriers., Practical Implications: It is important to encourage policy changes to reduce barriers to accessing oral health care, to continue pediatric dentists' participation with Medicaid programs, and to urge early dental services for children., (Copyright © 2019 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Metastatic breast cancer is a leading cause of cancer-related deaths in women worldwide. Patients with triple negative breast cancer (TNBCs), a highly aggressive tumor subtype, have a particularly poor prognosis. Multiple reports demonstrate that altered content of the multicopy mitochondrial genome (mtDNA) in primary breast tumors correlates with poor prognosis. We earlier reported that mtDNA copy number reduction in breast cancer cell lines induces an epithelial-mesenchymal transition associated with metastasis. However, it is unknown whether the breast tumor subtypes (TNBC, Luminal and HER2+) differ in the nature and amount of mitochondrial defects and if mitochondrial defects can be used as a marker to identify tumors at risk for metastasis. By analyzing human primary tumors, cell lines and the TCGA dataset, we demonstrate a high degree of variability in mitochondrial defects among the tumor subtypes and TNBCs, in particular, exhibit higher frequency of mitochondrial defects, including reduced mtDNA content, mtDNA sequence imbalance (mtRNR1:ND4), impaired mitochondrial respiration and metabolic switch to glycolysis which is associated with tumorigenicity. We identified that genes involved in maintenance of mitochondrial structural and functional integrity are differentially expressed in TNBCs compared to non-TNBC tumors. Furthermore, we identified a subset of TNBC tumors that contain lower expression of epithelial splicing regulatory protein (ESRP)-1, typical of metastasizing cells. The overall impact of our findings reported here is that mitochondrial heterogeneity among TNBCs can be used to identify TNBC patients at risk of metastasis and the altered metabolism and metabolic genes can be targeted to improve chemotherapeutic response., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Phosphatidylinositol 4 phosphate 5 kinase 1α (PIP5K) is mainly localized in the cytosol and plasma membrane. Studies have also indicated its prominent association with nuclear speckles. The exact nature of this nuclear pool of PIP5K is not clear. Using biochemical and microscopic techniques, we have demonstrated that the nuclear pool of PIP5K is modified by SUMO-1 in HEK-293 cells stably expressing PIP5K. Moreover, this SUMOylated pool of PIP5K increased during apoptosis. PolySUMO-2 chain conjugated PIP5K was detected by pull-down experiment using affinity-tagged RNF4, a polySUMO-2 binding protein, during late apoptosis., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The transcription factor Elf5 plays an important role in mammary gland development. However, because of the embryonic lethality of Elf5 straight knockout mice, prior studies have been limited to experiments with Elf5 haploinsufficient animals, overexpression systems or transplants. Here, we have utilized K14-Cre to generate mammary-gland specific Elf5 conditional knockout mice. During pregnancy, Elf5-null mammary epithelium completely failed to initiate alveologenesis, and a characteristic of virgin ductal epithelial cells persisted postpartum. We demonstrate that the loss of Elf5 leads to the absence of alveolar secretory markers confirming previous published data. Interestingly, the developmental block due to a lack of Elf5 could not be restored by multiple gestations. Elf5-null mammary epithelial cells also display disorganized cell structures as evident by altered cell polarities, which might be the cause for collapsed lumina. We observe reduced levels of Stat5 and attenuated Stat5 activity as measured by p-Stat5 levels both in Elf5-null mammary glands as well as cultured mammary epithelial cells. This data suggests that the failure of alveolar and lactogenic differentiation due to the loss of Elf5 is mediated in part due to impaired Stat5 activity. In support of this hypothesis, we show by ChIP experiments that Stat5a promoter contains a conserved Elf5-binding site that is occupied by Elf5 in mammary glands. Mammary epithelia lacking Elf5 exhibited downregulation of several other critical genes involved in alveologenesis, suggesting Elf5 as a master regulator in alveolar development. We propose a model for Elf5-mediated alveolar development, in which Elf5 regulates the expression of key mediators of the PrlR/Jak2/Stat5 signaling pathway.

Acute lymphopenia-induced homeostatic proliferation (HP) of T cells promotes antitumor immunity, but the mechanism is unclear. We hypothesized that this is due to a lack of inhibitory signals that allows activation of T cells with low affinity for self-antigens. Tumors resist immunity in part by expressing inhibitory molecules such as PD-1 ligand 1 (PD-L1), B7-H4, and TGF-beta. In irradiated mice undergoing HP, we found that T cells displayed a severe deficit in the activation-induced expression of inhibitory molecules PD-1 and CTLA-4, and TGF-beta1-induced expression of Foxp3. HP T cells were also less suppressed by B7-H4/Ig and, unlike control T cells, failed to produce IL-10 in response to this molecule. This deficiency in regulation was reversed as normal T-cell numbers were restored. We conclude that T cells are weakly regulated by inhibitory molecules during the acute phase of HP, which could explain their increased effectiveness in cancer immunotherapy.

The current goal in the treatment of diabetes is not only to enhance the glycemic control but also to improve the associated cardiovascular risk factors. Among many of the strategies available, a co-ligand of PPARalpha and gamma in a single molecule which combines the insulin sensitizing potential of PPARgamma and the beneficial lipid modulating properties of PPARalpha agonism, has gained attention in the recent past. Here we report the biochemical mechanism by which a dual PPAR alpha/gamma agonist Ragaglitazar (Raga) achieves this goal. The PPARalpha component of Raga appears to contribute to a significant increase in beta oxidation, ApoA1 secretion and inhibition of TG biosynthesis in HepG2 cells. These effects of Raga at 60 microM were similar to that shown by Fenofibrate (Feno) at 250 microM. The PPARgamma component of Raga showed significant G3PDH activity and TG accumulation with a corresponding increase in aP2 expression in 3T3L1 cells. Significantly reduced levels of IL-6 and TNFalpha were observed in the culture supernatants of Raga treated 3T3L1 cells. Raga resulted in significant insulin dependent glucose uptake in 3T3L1 with a corresponding increase in GLUT4 expression. Further, Raga showed a significant cholesterol efflux with a corresponding increase in ABCA1 protein expression in THP-1 macrophages. In conclusion, Raga activates both PPARalpha and gamma regulated pathway in adipocytes as well as in hepatocytes which together contributes for its insulin sensitizing and lipid lowering activity. In addition the dual activation of PPAR alpha/gamma also shows an athero-protective potential by inducing reverse cholesterol efflux and inhibiting the pro-inflammatory cytokines.

Ragaglitazar is a novel and potent dual peroxisome proliferators activated receptor (PPAR) alpha and gamma activator. The aim of this study is to investigate the effect of ragaglitazar on blood pressure and endothelial function in insulin resistant animal model and non-insulin resistant hypertensive models. The effects ragaglitazar were tested in Zucker fa/fa, spontaneously hypertensive rats (SHR), 2 kidney 1clip rat (2K1C) and Wistar Kyoto rats (WKY). Pioglitazone was taken as a comparative standard. Ragaglitazar showed significant reduction (P<0.001) of systolic blood pressure (SBP) in insulin resistant fa/fa rats, with concomitant reduction in plasma triglycerides (TG) and insulin levels while pioglitazone (10 mg kg(-1)) showed significant (P<0.05) but comparatively less reduction. Ragaglitazar in contrast to pioglitazone showed significant reduction (P<0.05) of SBP in SHR, 2K1C while the same dose did not have any effect on normotensive WKY. Ragaglitazar also showed significant improvement in acetylcholine-induced relaxation in isolated aorta of Zucker fa/fa, SHR, 2K1C and also potentiated the insulin-induced vasorelaxation in Zucker fa/fa rats. These findings summarize that ragaglitazar shows significant reduction of BP and improvement in endothelial function not only in insulin resistant but also in non-insulin resistant hypertensive models where standard thiazolidinediones are ineffective. These data indicates that dual PPARalpha and gamma activator ragaglitazar can be beneficial for the treatment of hypertension and vascular disease commonly associated with type 2 diabetes.

This study characterizes the molecular mechanisms necessary for glutamine synthesis in the human placenta. RNA hybridization and protein immunoblotting were used to verify the presence of glutamine synthetase (GS) transcripts and protein, respectively. Additionally, the presence of GS was determined by immunohistochemistry. RNA hybridization demonstrated the presence of 1.8- and 2.8-kB transcripts and protein immunoblotting yielded a single 49-kDa band, characteristics of GS transcripts and protein, respectively. The mean (+/- s.d.) specific activity of placental GS, expressed as mumol gamma-glutamyl hydroxamic acid/mg protein/h was 1.80 +/- 0.59, which is comparable to other organs which are net glutamine producers. Immunohistochemical analysis indicated the presence of GS within the cytotrophoblast and mesenchyme layers of placental villi, but not in the syncytiotrophoblast. Although these results suggest that the human placenta is capable of synthesizing glutamine, the fate of glutamine produced by this organ remains speculative.

Diets rich in polyunsaturated n-3 fatty acids can alter various macrophage functions. One possible mechanism by which this occurs is through modulation of the physicochemical properties of the cell membrane and the signal transduction pathways associated with macrophage activation. In this study, we investigated how n-3 fatty acids altered the signaling pathway of the lipid-based mediator platelet-activating factor (PAF). Macrophages from mice fed a diet containing n-3 fatty acids showed a greater increase in PAF-induced intracellular Ca2+ mobilization than macrophages from mice fed an n-6 fatty acid-rich diet. Macrophages treated in vitro with the n-3 fatty acids docosahexaenoic and eicosapentaenoic also showed higher intracellular Ca2+ mobilization than untreated or n-6 fatty acid-treated macrophages. Scatchard analysis of PAF binding showed the presence of one type of PAF receptor; their number and affinities were not altered by dietary fat. Mastoparan, which can activate G-protein-linked phosphoinositide (PI)-signaling pathway through the activation of G proteins, stimulated a higher Ca2+ mobilization in macrophages from mice fed n-3 compared to n-6 fatty acids. In addition, the response of macrophages from n-3-fed mice to PAF was less sensitive to phospholipase C inhibition than that of macrophages from those fed n-6 diets. The activity of phospholipase C in macrophages from mice fed n-3 diets was significantly higher than that of macrophages from mice fed diets containing n-6 fatty acids. Collectively, these results showed that n-3 fatty acids can enhance the PAF-signaling pathway in macrophages by increasing the activation potential of phospholipase C, without affecting PAF receptor number and affinity.

Tumor growth can be altered by the amount and type of fat in the diet. Although there are several possible mechanisms for this, recent work suggests that alterations in the immune system by dietary fat may affect tumorigenesis. The focus of recent studies has been on dietary fat modulation of macrophage function because that cell plays a pivotal role in many immune responses, including anti-tumor activity. One possible mechanism of dietary fat effects on macrophages is altered signal transduction, which, in turn, could alter gene regulation and macrophage function. Initial studies tested the effects of dietary fat on kinase activity after stimulation with interferon-gamma. Macrophages from mice fed menhaden fish oil (MFO) had slightly decreased protein kinase C activity compared with macrophages from mice fed safflower oil (SAF). No differences among the diets were observed when the activity of protein kinase A and G were tested. When calcium mobilization was tested, we found that macrophages from mice fed MFO had an increased response compared with macrophages from mice fed SAF. Dietary fat also modified the response of macrophages to platelet-activating factor with respect to the induction of Ia expression. In studies to identify genes involved in dietary fat effects on macrophage function, we screened a cDNA library of macrophages treated with prostaglandin E2 (PGE2), a lipid-based mediator that can modulate macrophage function and be altered by dietary fat. The cloned gene, BTG1, was enhanced in macrophages treated with PGE2, but the relationship with dietary fat remains to be determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain tissues of domestic cats that died of aplastic anemia from infection with either parental feline leukemia virus (FeLV), subgroup C, or a mixture of FeLV-C and recombinants between FeLV-C and an endogenous FeLV provirus were examined by the immunoperoxidase staining technique using a monoclonal antibody (C11D8) directed against an epitope of the viral surface glycoprotein (SU). Positive staining of the central nervous system (CNS) capillary endothelial cells with no labeling on neuronal or glial cells was observed in cats that were inoculated with the virus mixture. This was in contrast to brain tissue of cats infected with FeLV-C alone, which showed no such staining. While non-CNS endothelial cells derived from human umbilical vein (HUVEC) could be readily infected in culture by FeLV-C, endothelial cells derived from human retina (REC) or brain (BEC) were resistant to infection by this parental virus. These latter cells in culture, however, could be infected by the viral mixture. The data suggested that at least one or more of the presumptive recombinant viruses could specifically infect CNS-derived endothelial cells. Using polymerase chain reaction and DNA sequencing strategies to amplify and analyze DNA fragments of the proviral SU region from cells infected with REC-selected viruses, we found the occurrence of a single recombinant in which two-thirds of the SU gene from the N-terminus of FeLV-C was replaced by the endogenous FeLV element. This recombinant virus, when molecularly cloned, should be useful in determining its potential in vivo neuropathogenicity.

Fibrinolytic activity (FA) was measured by dilute blood clot lysis time at entry to the Northwick Park Heart Study in 1382 white men aged 40-64, of whom 179 subsequently experienced episodes of ischaemic heart disease during a mean follow-up period of 16.1 years. There was a significant interaction between age and low FA (p = 0.02) with respect to ischaemic heart disease: a difference of one standard deviation in FA was associated with a difference of about 40% in ischaemic heart disease risk (p = 0.002) in those aged 40-54 at entry. The FA association remained after adjusting for plasma fibrinogen. High fibrinogen concentrations themselves were also associated with ischaemic heart disease, as was high factor VII activity with fatal events. Low FA in younger men may exert a long-term influence by impairing the removal of fibrin deposits that contribute to atherogenesis. Low FA appears to be a leading determinant of ischaemic heart disease in younger men and methods of enhancing fibrinolytic activity, whether by life-style changes or pharmacologically, should be considered.

In 35 patients undergoing routine orthopaedic operations in which occlusive tourniquets were used there was a pronounced rise in fibrinolytic activity in the systemic circulation which lasted for at least 15 minutes after the release of the tourniquet; this response was seen after operations on both arms and legs. In contrast there was no increase in fibrinolytic activity in the systemic circulation associated with venous occlusion. Neither the application of a tourniquet nor venous occlusion resulted in changes in factors V or VIII, fibrinogen, or platelet-count. The application of a completely occlusive tourniquet might be a simple form of prophylaxis against deep-vein thrombosis and would avoid the disadvantages of using heparin.

In 15 women on oral contraceptives containing 30 microgram oestrogen, mean values for factors II, VII, and X, fibrinogen, fibrinolytic activity, antithrombin III, cholesterol, and fasting triglycerides were intermediate between values for 63 women on preparations containing 50 microgram oestrogen and those for 243 premenopausal women not on oral contraceptives. Mean blood-pressure levels, however, were higher in women on 30 microgram than in those on 50 microgram preparations. In 28 women on 50 microgram preparations containing 3 mg or 4 mg norethisterone, mean values of factor VII, fibrinogen, fibrinolytic activity, cholesterol, fasting triglycerides, and systolic blood-pressure were higher than in 15 women whose preparations contained only 1 mg of norethisterone. A less consistent picture was found in women on 30 microgram oestrogen preparations containing either 250 microgram (10 women) or 150 microgram (5 women) d-norgestrel. It is concluded that 30 microgram oestrogen preparations probably result in smaller hemostatic and lipid changes than 50 microgram preparations but that they may have a blood-pressure-raising effect attributable to the particular progestagen, d-norgestrel, used in 30 microgram preparations. The safety of these 30 microgram oestrogen preparations may thus depend partly on the balance between these two sets of effects. It is also concluded that norethisterone may have effects similar to those attributed to oestrogens.

18 patients with severe hypertriglyceridaemia (mean fasting plasma triglyceride 5.7 mmol/l) had significantly higher concentrations of plasma fibrinogen and clotting factor Xc than did a normolipidaemic comparison group. Fibrinolytic activity was significantly lower in the hyperlipidaemic patients. Six months of treatment (diet or diet and clofibrate) lowered the patients mean plasma triglyceride to 3.1 mmol/l and caused a fall of clotting factors VIIc and Xc and a significant rise in fibrinolytic activity. None of these variables changed in the comparison group. Raised fibrinogen and factor VIIc concentrations are risk factors for cardiovascular mortality, and raised factor Xc and lowered fibrinolytic activity have both been found in groups at high risk of ischaemic heart-disease. Despite the fact that in population studies triglycerides do not consistently appear to be an independent risk factor for ischaemic heart disease, these data suggest that a pronounced increase in triglycerides warrants energetic therapy because it may be associated with a "hypercoagulable state".

Components of the haemostatic system which may be involved in the pathogenesis of ischaemic heart disease (IHD) were measured in the Northwick Park Heart Study. Of 1510 white men aged 40-64 at recruitment, 49 have since died. 27 died from cardiovascular disease (IHD in all but 3), 18 from cancer, and 4 from other causes. The mean recruitment levels of factor VIIc, factor VIIIc, and fibrinogen were significantly higher in those who died of cardiovascular disease than in those who survived. The independent associations of factor VIIc and fibrinogen with cardiovascular death were at least as strong as the association of blood cholesterol with cardiovascular death. A clustering of two or three high clotting-factor values (factor VIIc, factor VIIIc, and fibrinogen) was present at recruitment in 63% of those who died of cardiovascular disease, compared with 23% of those who survived. The clotting-factor results appeared to be specific for cardiovascular disease: there was no evidence that high levels of factor VIIc, factor VIIIc, and fibrinogen were associated with death from cancer. The general epidemiology of factor VIIc, factor VIIIc, and fibrinogen is consistent with their having a role in the pathogenesis of IHD.

The Northwick Park Heart Study (NPHS) has investigated the thrombotic component of ischaemic heart disease (IHD) by the inclusion of measures of haemostatic function. Among 1511 white men aged between 40 and 64 at the time of recruitment, 109 subsequently experienced first major events of IHD. High levels of factor VII coagulant activity and of plasma fibrinogen were associated with increased risk, especially for events occurring within 5 years of recruitment. These associations seemed to be stronger than for cholesterol, elevations of one standard deviation in factor VII activity, fibrinogen, and cholesterol being associated with increases in the risk of an episode of IHD within 5 years of 62%, 84%, and 43% respectively. Multiple regression analyses indicated independent associations between each of the clotting factor measures and IHD but not between the blood cholesterol level and IHD incidence. The risk of IHD in those with high fibrinogen levels was greater in younger than in older men. Much of the association between smoking and IHD may be mediated through the plasma fibrinogen level. The biochemical disturbance leading to IHD may lie at least as much in the coagulation system as in the metabolism of cholesterol.