Search

In clinical trials that study people with a continuous measure defined categorically, even repeated measurements within a visit and over successive visits do not prevent error-free classification. We describe the design of a screening procedure for the Systolic Hypertension in the Elderly Program (SHEP), a randomized clinical trial designed to test whether regular administration of antihypertensive medication reduces the risk of stroke in elderly persons with isolated systolic hypertension. Data from a pilot study performed before the inauguration of SHEP allowed empirical study of a variety of possible screening rules for SHEP. A desirable screening rule would require only two screening visits, would lead to a randomized cohort with high mean systolic blood pressure, and would not impede recruitment. We emphasize two classes of rules, “serial” and “conditional.” A serial rule uses only the values observed at a given screen to determine eligibility to proceed to the next screen. A conditional rule uses the value observed at a given screen along with values already observed to determine eligibility to proceed. For the SHEP study, we chose a conditional rule for screening because of its efficiency in identifying eligible participants. Our approach to selection of screening rules should be applicable to other clinical trials in which the measurement that defines the primary entry criterion has considerable measurement error.

While surgery is commonly required for complications related to hemoglobin SC (HbSC) disease, little is known about the perioperative complications or the indications for preoperative transfusion in this group. We describe the patient characteristics, preoperative transfusion regimens, and outcome in 92 patients with HbSC and sickle-variants undergoing elective surgery. Thirty-eight percent of the patients were transfused preoperatively. Patients transfused were more likely to have been hospitalized in the year prior to the surgery and scheduled for abdominal procedures. Abdominal and ear, nose and throat procedures were the most common surgeries in our study. The overall complication rate was 18% and sickle cell-related complications occurred in 9% of patients. In patients undergoing intra-abdominal procedures, the incidence of sickle cell-related complications was significantly higher in those patients not transfused prior to their surgery (35 vs. 0%). There were two deaths. We recommend selective use of preoperative transfusion in patients with HbSC disease undergoing surgery. Transfusion appears to be beneficial in abdominal cases but is not necessary with minor procedures such as myringtomy. Am. J. Hematol. 57:101–108, 1998. © 1998 Wiley-Liss, Inc.

The liver is a truly remarkable organ when one considers the diversity of its many functions. This organ has a central role in nutrient (carbohydrate, protein and lipid) and vitamin metabolism and serves as an intermediary between dietary sources of energy and the extrahepatic tissues, which utilize such energy. Another major function is the detoxification and elimination of xenobiotic toxins and drugs, as well as endogenous metabolites, such as bilirubin. The liver is responsible for the synthesis of biologically important proteins (i.e., albumin, transferrin, clotting factors, complement factors, apolipoproteins, etc.). The liver synthesizes and secretes the components of bile, including bile acids, which are important for the intestinal solubilization and absorption of the products of lipid digestion. Finally, the liver has an important role in immune function, due primarily to its resident macrophage, the Kupffer cell.

The liver produces and secretes most of the circulating proteins in the body that function in an amazingly complex array of regulatory and metabolic processes. The liver also functions as a central metabolic way station for the processing, partitioning and trafficking of nutrients, including lipids and carbohydrates, as well as vitamins, at the intersection of the intestine and the rest of the body. It is remarkable that the regulatory mechanisms that have evolved to control these processes generally function in a highly responsive and coordinated manner. However, when dysregulation occurs due to genetic or environmental factors, such as in glycogen storage diseases or non-alcoholic fatty liver disease, significant morbidity may result. This chapter will highlight these functions of the liver and some of the disease processes that may occur.

The IPEC-1 newborn swine intestinal epithelial cell line was used to determine the effects of the uptake of various fatty acids on the secretion of apolipoprotein (apo) B and apo A-I, as well as triglyceride and phospholipid. Long-chain saturated fatty acids were taken up and stimulated triglyceride synthesis, and palmitic (16:0) and stearic (18:0) acids also stimulated phospholipid synthesis. However, these fatty acids did not enhance triglyceride, phospholipid, or apo B or apo A-I secretion. Oleic acid (18:1) was the most effective of all fatty acids tested in stimulating triglyceride synthesis and the secretion of triglyceride, phospholipid, and apo B. Linoleic (18:2) and linolenic (18:3) acids were no more effective than long-chain saturated fatty acids in stimulating these processes. With saturated fatty acids, apo A-I followed the same secretory pattern as apo B. However, among the unsaturated fatty acids, oleic acid was the least effective and linolenic acid was the most effective in stimulating apo A-I secretion. Basolateral secretion of lipid and apolipoproteins by differentiated IPEC-1 cells is differentially regulated by apical exposure to fatty acids.

Background and Aim: Pediatric gastroenterology is the only pediatric subspecialty with nutrition as part of its official curriculum and objective; however, pediatric gastroenterology fellows believe that their baseline knowledge in nutrition is suboptimal. The purpose of the present study was to assess the perceived effectiveness of nutrition training among pediatric gastroenterologists, identify areas of need for additional education, and determine the perceived role of the gastroenterologist in obesity management. Methods: A survey was sent to members and fellows of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition to assess general nutrition education as well as obesity management and educational needs. Results: A total of 272 responses were received, for an overall response rate of 15.2% (272/1784). Most responders reported having average or above-average knowledge base in all nutritional topics. There was strong interest in additional resources and a continuing medical education (CME) module on several nutrition topics including nutritional requirements in specific gastrointestinal (GI) disease, failure to thrive/growth failure, and parenteral nutrition support, with the format of CME dependent on the topic. There was also a strong interest in additional CME on the management of pediatric obesity (67%), as most responders believed that the management of obesity in children requires subspecialty care. The perceived role of the pediatric gastroenterologist was, however, one of support to treat the GI and hepatic comorbidities of obesity rather than serve as the main provider of comprehensive obesity care. Conclusions: Pediatric gastroenterologists identified gaps in their nutrition knowledge base that may be attributed to the present nutrition education training during fellowship. Multiple topics were identified for additional nutrition education, including obesity management. The nutrition management challenges of today necessitate improved baseline nutrition knowledge and this focus on nutrition should begin at the fellowship level.

Despite clinical research and medical advances, care of the preterm infant remains a clinical challenge, with the immature gastrointestinal (GI) system limiting the types and amounts of nutrients that can be provided enterally to meet energy and nutrient requirements. Progress in understanding the relationship between dietary inputs and the developing GI system after preterm birth has been limited by ethical constraints of using preterm infants as experimental subjects and a lack of relevant animal models. We review development of the GI system of the pig during gestation, the similarities shared with human fetuses, and the responses to dietary stimuli. The GI systems of pigs and humans develop early in gestation, with growth and maturation accelerating during the final weeks prior to birth. As a consequence, deficits in GI digestive capacities are directly related to how early in gestation an infant or pig is delivered, thereby complicating attempts to provide adequate enteral nutrients for growth and development. Pigs differ from humans by being born with low activities of the brush border membrane carbohydrases necessary for hydrolysis of nonlactose carbohydrates. Fetuses of both species have impaired lipid digestion coinciding with lipid malabsorption after preterm birth. Protease activity, although present, may not be adequate and may limit growth potential. Undigested enteral inputs are available to the resident bacteria and the production of metabolites can influence health and nutrition. The preterm pig represents a relevant and translational animal model for understanding GI development and for identifying diet and regulatory factors that stimulate GI growth and maturation after preterm birth and thereby accelerate the transition from parenteral nutrition to full enteral nutrition.

The purpose of this study was to determine the effects of dietary fatty acids on intestinal apolipoprotein (apo) A-IV and C-III expression in the newborn piglet. Two-day-old female piglets received one of three isocaloric formulas containing medium-chain triglycerides (TG) (MCT), intermediate-chain saturated TG (ICST), or long-chain polyunsaturated TG (LCPUT) by continuous duodenal infusion for 24 hrs. Control groups received a low-TG elemental formula infusion (LTG group) and a high-TG long-chain unsaturated lipid emulsion infusion (HTG group). Jejunal synthesis of both apo A-IV and C-III was increased by all infusions compared to the LTG group. Apo A-IV and C-III mRNA levels paralleled synthesis levels except for apo C-III with the MCT diet, where regulation appeared to occur at the translational level. Among all groups, apo A-IV synthesis and mRNA abundance were linearly correlated with that of apo C-III.

OBJECTIVE: To determine if insulin-like growth factor 1 (IGF-1) is associated with strength and functional ability in healthy older men. DESIGN: Cross-sectional study. SETTING: San Francisco Department of Veterans Affairs Medical Center. PARTICIPANTS: One hundred four ambulatory community-dwelling men. MEASUREMENTS: Serum IGF-1 levels were obtained. Measured variables included strength of the knee flexors and extensors, handgrip, score on the Physical Performance Test, body composition, and three tests of cognitive function. RESULTS: The subjects' mean age was 75.5±4.9 (SD) years (range 70–94 years), and their mean IGF-1 level was 134.7±43.6 ng/mL. The univariate association of age with the variables was much stronger than the univariate association of IGF-1 with the same variables. In multivariable models, age, but not IGF-1, was associated with the variables. CONCLUSION: In this study of healthy older men, age is the most important variable in predicting functional decline. There was no association of IGF-1 levels to functional status independent of age. J Am Geriatr Soc 43:1350–1355,1995.

Background Preoperative transfusions are frequently given to prevent perioperative morbidity in patients with sickle cell anemia. There is no consensus, however, on the best regimen of transfusions for this purpose. Methods We conducted a multicenter study to compare the rates of perioperative complications among patients randomly assigned to receive either an aggressive transfusion regimen designed to decrease the hemoglobin S level to less than 30 percent (group 1) or a conservative regimen designed to increase the hemoglobin level to 10 g per deciliter (group 2). Results Patients undergoing a total of 604 operations were randomly assigned to group 1 or group 2. The severity of the disease, compliance with the protocol, and the types of operations were similar in the two groups. The preoperative hemoglobin level was 11 g per deciliter in group 1 and 10.6 g per deciliter in group 2. The preoperative value for hemoglobin S was 31 percent in group 1 and 59 percent in group 2. The most frequent operations w...

The purpose of this study was to determine precision and diagnostic capability of bone mineral density measurements using lateral dual-energy X-ray absorptiometry (DXA) of the lumbar spine in supine position. Duplicate postero-anterior (PA) and lateral DXA measurements were performed in 60 women. Precision errors of the single vertebral levels using lateral DXA ranged from 3.3% to 4.9%. The combination of all levels improved the precision errors to 2.0%. Paired PA and lateral DXA measurements (Hologic QDR 2000) including the vertebral levels L2 to L4 were performed in 331 postmenopausal women. In 42 women an overlap of L4 by the pelvis was suspected on the lateral DXA images. Vertebral fractures were assessed as a fracture/non-fracture dichotomy. L4 and combinations of vertebrae including L4 showed the best discriminatory capabilities with respect to vertebral fractures in receiver operating characteristic (ROC) analyses,t-tests andZ-scores, with smaller variability of the results when multiple vertebral levels were used. The areas under the ROC curves were 0.662 and 0.639 for lateral and PA measurements of L2 to L4, respectively when all women were included. Excluding the women with pelvic overlap on lateral DXA scans improved the ROC area for lateral scans to 0.686 while that for PA scans remained almost constant (0.641). The differences between PA and lateral measurements were not statistically significant. In 162 women of our study cohort an additional quantitative computed tomography (QCT) measurement of the vertebral levels L2 to L4 was performed and overlapping bony structures at the three levels were studied. Overlapping bony structures were found on QCT slices in 96.9% at the L2 level and in 31.5% at the L3 level. At the L4 level an overlap was found in 5.6% of the women in addition to 31 women in whom L4 overlap had been suspected on DXA images. In total, the level L4 was overlapped in 24.7% of the women. Lateral DXA measurements of the lumbar spine with the patient in supine position are meaningful for diagnosis and follow-up of osteopenia. The inclusion of a maximum number of vertebrae, i.e. L2 to L4 (if L4 is not overlapped by pelvic bone), improves precision and diagnostic capability of the method.

Background Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. Methods We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. Results During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using one's arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. Conclusions Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.

Compared with white women, Asian women have about a 40%-50% and blacks a 50%-60% lower risk of hip fracture, but the reason for this racial difference is not known. Women with a shorter hip axis have a lower risk of hip fracture. To test the hypothesis that a shorter hip axis length could account for the lower risk of hip fracture among Asian and black women, we measured hip axis length in 135 Caucasian, 74 Asian and 50 black women. The mean hip axis lengths of Asian and black women were significantly shorter (1.2 and 0.7 standard deviations, respectively) than that of the whites (p < 0.0001). We estimate that, compared with white women, Asians would have a 47% lower risk (95% confidence interval: 32%-63%) and blacks would have a 32% (15%-45%) lower risk of hip fracture because of their shorter hip axis. We conclude that a shorter hip axis length might be a major factor accounting for Asian women's lower risk of hip fracture and might contribute to the lower risk in black women.

Clinical studies have demonstrated improvement of parenteral nutrition (PN)-associated liver disease (PNALD) with ω3 polyunsaturated fatty acid (ω3PUFA) supplementation containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Experiments were designed to test the following hypotheses: (1) therapeutic effects of ω3PUFA are due to attenuation of cellular apoptosis induced by hydrophobic bile acid exposure, which occurs in cholestasis, and (2) attenuation of apoptosis by EPA and DHA is additive or synergistic.Cultured HepG2 cells were treated with 50-200 µM chenodeoxycholic acid (CDCA) in the presence and absence of EPA, DHA, or EPA + DHA. Apoptosis was evaluated using cell staining with fluorescence microscopy and the Apo-ONE Homogeneous Caspase-3/7 assay. Specific apoptotic mediators were evaluated with quantitative RT-PCR.Treatment with EPA alone and DHA alone resulted in 22% and 9% attenuation of caspase-3/7 activity, respectively. Caspase-3/7 activity was attenuated by 52% when cells were treated with a combination of EPA and DHA (P = .0034). Treatment with EPA alone, DHA alone, and the combination of EPA and DHA all resulted in equal attenuation of apoptotic mediator gene expression.The combination of EPA and DHA resulted in a synergistic attenuation of bile acid-induced hepatocellular apoptosis, as assessed by caspase-3/7 activity, compared to EPA and DHA separately. The combination of EPA and DHA did not result in a synergistic attenuation of the upregulation of Fas or TRAIL-R2. These data suggest that EPA and DHA may be working via multiple intracellular pathways to attenuate bile acid-induced apoptosis.

BACKGROUND: Inhaled nitric oxide (iNO) is an effective therapy for pulmonary hypertension and hypoxic respiratory failure in term infants. Fourteen randomized controlled trials (n = 3430 infants) have been conducted on preterm infants at risk for chronic lung disease (CLD). The study results seem contradictory. DESIGN/METHODS: Individual-patient data meta-analysis included randomized controlled trials of preterm infants ( RESULTS: Data from 3298 infants in 12 trials (96%) were analyzed. There was no statistically significant effect of iNO on death or CLD (59% vs 61%: relative risk [RR]: 0.96 [95% confidence interval (CI): 0.92–1.01]; P = .11) or severe neurologic events on imaging (25% vs 23%: RR: 1.12 [95% CI: 0.98–1.28]; P = .09). There were no statistically significant differences in iNO effect according to any of the patient-level characteristics tested. In trials that used a starting iNO dose of >5 vs ≤5 ppm there was evidence of improved outcome (interaction P = .02); however, these differences were not observed at other levels of exposure to iNO. This result was driven primarily by 1 trial, which also differed according to overall dose, duration, timing, and indication for treatment; a significant reduction in death or CLD (RR: 0.85 [95% CI: 0.74–0.98]) was found. CONCLUSIONS: Routine use of iNO for treatment of respiratory failure in preterm infants cannot be recommended. The use of a higher starting dose might be associated with improved outcome, but because there were differences in the designs of these trials, it requires further examination.

Study Objective. To evaluate the use of enteral fish oil for the treatment of parenteral nutrition-associated liver disease (PNALD). Design. Retrospective case series. Setting. Pediatric academic hospital and outpatient clinic. Patients. Six parenteral nutrition-dependent infants with short-bowel syndrome and PNALD. Measurements and Main Results. The six infants received supplementation with enteral fish oil, and treatment was evaluated over a 12-week period. The PNALD, as reflected by elevated total bilirubin levels, completely reversed in four of the six infants within a mean ± SD of 5 ± 2.6 weeks (range 2–8 wks) after initiation of the enteral fish oil supplementation. In addition, improvement in enteral feedings occurred after starting enteral fish oil therapy. Conclusion. Enteral fish oil may be an effective adjunctive treatment option for infants with PNALD, particularly for those infants with PNALD who are tolerating some amount of enteral nutrition as the result of an adequate amount of small bowel.

The objective of this study was to determine the effect of once-yearly zoledronic acid on the number of days of back pain and the number of days of disability (ie, limited activity and bed rest) owing to back pain or fracture in postmenopausal women with osteoporosis. This was a multicenter, randomized, double-blind, placebo-controlled trial in 240 clinical centers in 27 countries. Participants included 7736 postmenopausal women with osteoporosis. Patients were randomized to receive either a single 15-minute intravenous infusion of zoledronic acid (5 mg) or placebo at baseline, 12 months, and 24 months. The main outcome measures were self-reported number of days with back pain and the number of days of limited activity and bed rest owing to back pain or a fracture, and this was assessed every 3 months over a 3-year period. Our results show that although the incidence of back pain was high in both randomized groups, women randomized to zoledronic acid experienced, on average, 18 fewer days of back pain compared with placebo over the course of the trial (p = .0092). The back pain among women randomized to zoledronic acid versus placebo resulted in 11 fewer days of limited activity (p = .0017). In Cox proportional-hazards models, women randomized to zoledronic acid were about 6% less likely to experience 7 or more days of back pain [relative risk (RR) = 0.94, 95% confidence interval (CI) 0.90–0.99] or limited activity owing to back pain (RR = 0.94, 95% CI 0.87–1.00). Women randomized to zoledronic acid were significantly less likely to experience 7 or more bed-rest days owing to a fracture (RR = 0.58, 95% CI 0.47–0.72) and 7 or more limited-activity days owing to a fracture (RR = 0.67, 95% CI 0.58–0.78). Reductions in back pain with zoledronic acid were independent of incident fracture. Our conclusion is that in women with postmenopausal osteoporosis, a once-yearly infusion with zoledronic acid over a 3-year period significantly reduced the number of days that patients reported back pain, limited activity owing to back pain, and limited activity and bed rest owing to a fracture.

The nucleotide sequence of the swine apoA-I gene (encoding apolipoprotein) has been determined. The structure of the gene is similar to that of the human gene, and the exons exhibit a high degree of homology with those of the human gene. The porcine apoA-I gene is located adjacent to the apoC-III gene, as in humans.

Apolipoprotein (apo) A-IV overexpression enhances chylomicron (CM) assembly and secretion in newborn swine intestinal epithelial cells by producing larger particles (Lu S, Yao Y, Cheng X, Mitchell S, Leng S, Meng S, Gallagher JW, Shelness GS, Morris GS, Mahan J, Frase S, Mansbach CM, Weinberg RB, Black DD. J Biol Chem 281: 3473–3483, 2006). To determine the impact of apo A-IV on microsomal triglyceride transfer protein (MTTP), IPEC-1 cell lines containing a tetracycline-regulatable expression system were used to overexpress native swine apo A-IV and “piglike” human apo A-IV, a mutant human apo A-IV with deletion of the EQQQ-rich COOH-terminus, previously shown to upregulate basolateral triglyceride (TG) secretion 5-fold and 25-fold, respectively. Cells were incubated 24 h with and without doxycycline and oleic acid (OA, 0.8 mM). Overexpression of the native swine apo A-IV and piglike human apo A-IV increased MTTP lipid transfer activity by 39.7% ( P = 0.006) and 53.6% ( P = 0.0001), respectively, compared with controls. Changes in mRNA and protein levels generally paralleled changes in activity. Interestingly, native swine apo A-IV overexpression also increased MTTP large subunit mRNA, protein levels, and lipid transfer activity in the absence of OA, suggesting a mechanism not mediated by lipid absorption. Overexpression of piglike human apo A-IV significantly increased partitioning of radiolabeled OA from endoplasmic reticulum (ER) membrane to lumen, suggesting increased net transfer of membrane TG to luminal particles. These results suggest that the increased packaging of TG into nascent CMs in the ER lumen, induced by apo A-IV, is associated with upregulation of MTTP activity at the pretranslational level. Thus MTTP is regulated by apo A-IV in a manner to promote increased packaging of TG into the CM core, which may be important in neonatal fat absorption.

We examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 child-bearing urban women in Rwanda, central Africa. Although 68% of women reported only one lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Before receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the three primary routes of infection. However, only 16% of women reported taking any action to avoid AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of women had ever tried condoms, and many (68%) thought they could be dangerous to use. Women who perceived themselves at risk of AIDS (57%) were more likely to report changing behavior; they were also more likely to be infected with HIV. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partner, and believing that condoms are not dangerous. Future interventions should enhance perception of risk, encourage male sexual partners to reduce risky behavior, and increase familiarity with condoms.The authors examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 childbearing urban women in Rwanda, central Africa. Although 68% of them reported only 1 lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Prior to receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the 3 primary routes of infection. However, only 16% reported taking any action to prevent AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of the women has ever tried condoms, and many (68%) thought they could by dangerous to use. Those women who perceived themselves at risk for AIDS (57%0 were more likely to report changing behavior; they were also more likely to be HIV-infected. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partners, and believing that condoms are not dangerous. Future interventions should enhance the perception of risk, should encourage male sexual partners to reduce risktaking behavior, and should increase familiarity with condoms.

To assess the incidence of histological esophagitis in infants

Fetal, newborn, and suckling piglets were used to study the intestinal expression of the apoA-IV gene in the immature mammal. Swine apoA-IV (42 kD) was isolated from fat-fed piglet lipoprotein-deficient plasma by adsorption to Intralipid followed by preparative sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and electroelution. Rabbit anti-swine apoA-IV antibodies were raised, and apoA-IV was immunoprecipitated from small intestinal homogenates after in vivo radiolabeling with [3H]leucine. ApoA-IV synthesis was expressed as a percentage of total protein synthesis from trichloroacetic acid-precipitable counts. Fetal (40 day gestation) whole small intestine synthesis was 2.1%. Postnatally, 2-day-old newborn piglets given high triglyceride and low triglyceride duodenal infusions, as well as bile diversion, were studied. Synthesis rates in jejunal mucosa in all groups were comparable to the fetal whole intestinal value except in the jejunum of the high-triglyceride group, where synthesis was increased sevenfold. In 1- to 2-week-old fasting, cream-fed, and bile-diverted piglets synthesis was again unchanged except in the fat-fed jejunum, where synthesis doubled. Ileal synthesis rates in newborn and suckling animals were lower than jejunal rates and did not increase with lipid absorption or decrease with bile diversion. Northern blot hybridization of intestinal RNA samples from the newborn groups with an authentic cross-hybridizing human apoA-IV cDNA probe revealed a 1.8 kb signal which was strongest in the high-triglyceride jejunal samples. Slot blot hybridization showed eightfold increased apoA-IV mRNA levels in high-triglyceride jejunal samples as compared to low-triglyceride and bile-diverted jejunum with no differences in beta actin mRNA abundance.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatocyte nuclear factor-4alpha (HNF-4alpha) regulates transcription of several genes involved in lipid metabolism, including that of apolipoprotein (apo) A-IV, which is tightly regulated by lipid absorption and enhances enterocyte chylomicron secretion. Studies were performed to define the role of HNF-4alpha in the regulation of apo A-IV gene transcription by dietary fatty acid in neonatal swine small intestine. HNF-4alpha mRNA was expressed in liverintestinekidney in suckling, weanling, and weaned pigs. Jejunal HNF-4alpha mRNA and protein and apo A-IV and swine microsomal triglyceride transfer protein (MTP) large subunit mRNA expression were induced in parallel in 2-day-old swine by a 24-h high-fat intraduodenal infusion. In IPEC-1 cells, incubation with oleic acid (OA) resulted in coordinate induction of both HNF-4alpha, apo A-IV, and MTP mRNA, similar to that observed in vivo. When HNF-4alpha expression was driven by doxycycline by using the TET-On system in the absence of OA to observe the effect of HNF-4alpha directly on apo A-IV and MTP mRNA levels in the absence of other factors that might be concomitantly induced by fatty acid absorption, apo A-IV and MTP expression were increased. In luciferase reporter gene assays in IPEC-1 cells using apo A-IV/C-III intergenic region constructs, TET-On-regulated HNF-4alpha expression without OA increased luciferase activity, and incubation with OA did not further increase activity. These data suggest that acute induction of the apo A-IV and MTP genes by dietary lipid in newborn intestine occurs, at least in part, via ligand-independent transactivation by HNF-4alpha that is itself induced by a lipid-mediated mechanism.

The newborn mammal must efficiently absorb dietary fat, predominantly as triacylglycerol, and produce chylomicrons to deliver this lipid to peripheral tissues. The cellular mechanisms involved in enterocyte chylomicron assembly have recently been elucidated, and data on their regulation in the immature gut are beginning to emerge. This review focuses on key proteins involved in chylomicron assembly: apolipoprotein B-48, microsomal triglyceride transfer protein, and apolipoproten A-IV. Recent studies support a role for apolipoprotein A-IV in enhancing chylomicron secretion by promoting production of larger particles. These proteins are regulated in a manner to maximize the lipid absorptive capacity of the newborn intestine.

Intestinal apolipoprotein A-IV expression is highly regulated by dietary lipid in newborn swine, suggesting a role in lipid absorption. Constitutive overexpression of apoA-IV in newborn swine enterocytes enhances basolateral secretion of triacylglycerol (TG) in TG-rich lipoproteins 4.9-fold (Lu, S., Yao, Y., Meng, S., Cheng, X., and Black, D. D. (2002) J. Biol. Chem. 277, 31929-31937). To investigate the mechanism of this enhancement, IPEC-1 cells were transfected with a tetracycline-regulatable expression system (Tet-On). In cells incubated with oleic acid, a dose response relationship was observed between medium doxycycline concentration and basolateral apoA-IV and TG secretion. Similarly regulated expression of apoA-I did not enhance lipid secretion. The mean diameter of TG-rich lipoproteins secreted from doxycycline-treated cells was larger than from untreated cells (87.0 nm versus 53.4 nm). Basolateral apoB secretion decreased. Using the same expression system, full-length human apoA-IV (376 amino acids); a "pig-like" human apoA-IV, lacking the C-terminal EQQQ repeats (361 amino acids); and a "chicken-like" apoA-IV, further truncated to 343 amino acids, were expressed in IPEC-1 cells. With increasing protein secretion, cells expressing the full-length human apoA-IV displayed a 2-fold increase in TG secretion; in sharp contrast, cells expressing the pig-like human apoA-IV displayed a 25-fold increase in TG secretion and a 27-fold increase in lipoprotein diameter. When human apoA-IV was further truncated to yield a chicken-like protein, TG secretion was inhibited. We conclude that overexpression of swine apoA-IV enhances basolateral TG secretion in a dose-dependent manner by increasing the size of secreted lipoproteins. These data suggest that the region in the human apoA-IV protein from residues 344 to 354 is critical to its ability to enhance lipid secretion, perhaps by enabling the packaging of additional core TG into chylomicron particles. The EQQQ-rich region may play an inhibitory or modulatory role in chylomicron packaging in humans.

To review the effect of alendronate on bone density and fractures in postmenopausal women.We searched MEDLINE, EMBASE, Current Contents, and the Cochrane Controlled trials registry from 1980 to 1999, and we examined citations of relevant articles and proceedings of international meetings.We included 11 trials that randomized women to alendronate or placebo and measured bone density for at least 1 yr.For each trial, three independent reviewers assessed the methodological quality and abstracted data.The pooled relative risk (RR) for vertebral fractures in patients given 5 mg or more of alendronate was 0.52 [95% confidence interval (CI), 0.43-0.65]. The RR of nonvertebral fractures in patients given 10 mg or more of alendronate was 0.51 (95% CI 0.38-0.69), an appreciably greater effect than for the 5 mg dose. We found a similar reduction in RR across nonvertebral fracture types; in particular, RR reductions for fractures traditionally thought to be "osteoporotic," such as hip and forearm, were very similar to RR reductions for "nonosteoporotic" fractures. Individual studies showed similar results, reflected in the P values of the test of heterogeneity (P = 0.99 for vertebral and 0.88 for nonvertebral fractures). Alendronate produced positive effects on the percentage change in bone density, which increased with both dose and time. After 3 yr of treatment with 10 mg of alendronate or more, the pooled estimate of the difference in percentage change between alendronate and placebo was 7.48% (95% CI 6.12-8.85) for the lumbar spine (2-3 yr), 5.60% (95% CI 4.80-6.39) for the hip (3-4 yr), 2.08% (95% CI 1.53-2.63) for the forearm (2-4 yr), and 2.73% (95% CI 2.27-3.20) for the total body (3 yr). Heterogeneity of the treatment effect of alendronate was not consistently explained by any of our a priori hypotheses; in particular, the effect was very similar in prevention and treatment studies. The pooled RR for discontinuing medication due to adverse effects for 5 mg or greater of alendronate was 1.15 (95% CI 0.93-1.42). The pooled RR for discontinuing medication due to gastro-intestinal (GI) side effects for 5 mg or greater was 1.03 (0.81-1.30, P = 0.83), and the pooled RR for GI adverse effects with continuation of medication was 1.03 (0.98 to 1.07) P = 0.23.Alendronate increases bone density in both early postmenopausal women and those with established osteoporosis while reducing the rate of vertebral fracture over 2-3 yr of treatment. Reductions in nonvertebral fractures are evident among postmenopausal women without prevalent fractures and have bone mineral density (BMD) levels below the World Health Organization threshold for osteoporosis. The impact on fractures appears consistent across all fracture types, casting doubt on traditional distinctions between osteoporotic and nonosteoporotic fractures.

To define the developmental expression of microsomal triglyceride transfer protein (MTP) large subunit mRNA and protein, samples of small intestine and liver were collected from 40-day gestation fetal, 2-day-old newborn, 3-week-old suckling, and 2-month-old weanling swine. In fetal animals, MTP mRNA expression was high in intestine and liver. Postnatally, jejunal expression paralleled the intake of a high-fat breast milk diet and declined after weaning. Ileal expression was comparable with that of jejunum in 2-day-old animals, but declined to low levels afterward. Hepatic expression declined postnatally and remained low. MTP protein expression generally paralleled mRNA expression, except in fetal intestine in which no 97 kDa protein was detected. In 2-day-old piglets, a high-triacylglycerol diet increased jejunal and ileal MTP mRNA levels, as compared to a low-triacylglycerol diet. To test the roles of glucocorticoids and fatty acids in MTP regulation, a newborn swine enterocyte cell line (IPEC-1) was used. Except at day 2 of differentiation, dexamethasone did not influence MTP expression. Fatty acids either up-regulated or down-regulated MTP expression, depending on the specific fatty acid and duration of exposure. Although programmed genetic cues regulate MTP expression during development, clearly the amount and fatty acid composition of dietary lipid also play regulatory roles.

The diagnosis of osteoporosis is made from the measurement of BMD. DXA at the hip is the appropriate diagnostic site. Current clinical guidelines follow the principle that BMD measurements are indicated in individuals with risk factors for fracture and that treatment is recommended in those with a BMD below a critical value. In some countries reimbursement for the costs of treatment depend upon such thresholds for BMD. In Europe the critical value corresponds to a T-score of-2.5 SD, whereas in the USA less stringent criteria are used. It is evident, however, that fracture risk at any given T-score varies markedly according to age and other risk factors. This has led to the view that interventions should be targeted to those at high risk, irrespective of a fixed BMD threshold. In this sense, BMD is utlized as a risk assessment, since in many instances intervention thresholds will be less stringent than the diagnostic threshold. Thus, intervention thresholds need to differ from diagnostic thresholds and be based on fracture probabilities. A 10-year fracture probability appears to be an appropriate time frame. There are a number of problems to be overcome in the development of assessment guidelines. They need to take account of not only the risk of hip fracture but also that of other fractures which contribute significantly to morbidity, particularly in younger individuals. A promising approach is to weight fracture probabilities according to the disutility incurred compared with hip fracture probability. Account also needs to be taken of the large geographic variation in fracture probabilities worldwide. A further challenge for the future will be to identify risk factors that predict fracture with high validity in different regions of the world and their independent contributions, so that models of risk prediction can be constructed and ultimately validated in independent cohorts.

Apolipoprotein A-IV (apoA-IV) has myriad functions, including roles as a post-prandial satiety factor and lipid antioxidant. ApoA-IV is expressed in mammalian small intestine and is up-regulated in response to lipid absorption. In newborn swine jejunum, a high fat diet acutely induces a 7-fold increase in apoA-IV expression. To determine whether apoA-IV plays a role in the transport of absorbed lipid, swine apoA-IV was overexpressed in a newborn swine enterocyte cell line, IPEC-1, followed by analysis of the expression of genes related to lipoprotein assembly and lipid transport, as well as quantitation of lipid synthesis and secretion. A full-length swine apoA-IV cDNA was cloned, sequenced, and inserted into a Vp and Rep gene-deficient adeno-associated viral vector, containing the cytomegalovirus immediate early promoter/enhancer and neomycin resistance gene, and was used to transfect IPEC-1 cells. Control cells were transfected with the same vector minus the apoA-IV insert. Using neomycin selection, apoA-IV-overexpressing (+AIV) and control (-AIV) clones were isolated for further study. Both undifferentiated (-D) and differentiated (+D) +AIV cells expressed 40- to 50-fold higher levels of apoA-IV mRNA and both intracellular and secreted apoA-IV protein compared with -AIV cells. Expression of other genes was not affected by apoA-IV overexpression in a manner that would contribute to enhanced lipid secretion. +D +AIV cells secreted 4.9-fold more labeled triacylglycerol (TG), 4.6-fold more labeled cholesteryl ester (CE), and 2-fold more labeled phospholipid (PL) as lipoproteins, mostly in the chylomicron/very low density lipoprotein (VLDL) density range. ApoA-IV overexpression in IPEC-1 cells enhances basolateral TG, CE, and PL secretion in chylomicron/VLDL particles. This enhancement is not associated with up-regulation of other genes involved in lipid transport. ApoA-IV may play a role in facilitating enterocyte lipid transport, particularly in the neonate receiving a diet of high fat breast milk.

Background Painful vertebral fractures that come to medical attention (CVFx) comprise less than a third of all new vertebral deformities (VDef), yet account for a large proportion of the pain and disability due to vertebral osteoporosis. Little is known about the natural history of back pain and related disability before and after a CVFx. Objectives We compared prefracture levels of back pain and back disability in women who subsequently experienced a CVFx to levels of back pain and disability in women who did not have a CVFx, and examined the duration of increased back pain and disability for 12 months following a CVFx. Methods We studied 6,459 women in the Fracture Intervention Trial, aged 55–80 with femoral neck BMD T-score Results Women who had a single new CVFx > = 6 months after baseline had greater baseline disability than women who had neither a CVFx nor a VDef during FU, adjusting for age, number of baseline VDef, spine BMD, prior Dx of spine fracture, Geriatric Depression Score and treatment assignment. Women with only a new VDef but no CVFx had intermediate levels of prefracture back pain and disability. Women suffering a CVFx reported a mean of 6 days of severe back pain and 6 days of back disability for the 3 month period before the fracture, and 18 and 32 days (both P Conclusion Older women who have chronic back pain are more likely to suffer a CVFx. In those who have a CVFx, average back disability remains above prefracture levels for at least a year after the fracture. Prevention of fractures may be especially beneficial in older women with chronic back pain.

Background Objectives To describe the behaviour of the relative risk (RR), absolute risk reduction (ARR), and number needed to treat (NNT) by attained age for the hip, spine or forearm for alendronate treatment in women with osteoporosis. Methods 3658 women with osteoporosis from the Fracture Intervention Trial were followed for 3 to 4.5 years and treated with alendronate (ALN) at 5 mg/day for 2 years followed by 10 mg/day for the remainder of the trial. The age groups used in the analysis were: 55–65, 65–70, 70–75 and 75–85. All fractures were confirmed by x-rays. Results Risk reduction of hip, spine and forearm fractures were 53% (RR = 0.47, p Conclusion Alendronate is very effective in reducing the risk of osteoporotic fractures, regardless of age.

Long-chain polyunsaturated fatty acids (LC-PUFA) are important in the development of the immature nervous system, and adding these fatty acids to infant formula has been proposed. To determine the effect of n-3 LC-PUFA on apolipoprotein secretion and lipid synthesis in newborn swine enterocytes, differentiated IPEC-1 cells were incubated for 24 h with docosahexaenoic acid (DHA; 22:6) or eicosapentaenoic acid (EPA; 20:5) complexed with albumin at a fatty acid concentration of 0.8 mM or albumin alone (control) added to the apical medium. Oleic acid (OA; 18:1) was used a control for lipid-labeling studies. Both DHA and EPA reduced apolipoprotein (apo) B secretion by one-half, whereas EPA increased apo A-I secretion. The increased apo A-I secretion occurred primarily in the high-density lipoprotein fraction. These changes in apoprotein secretion were not accompanied by significant changes in synthesis. Modest decreases in apo B mRNA levels were observed for DHA and EPA, whereas there were no changes in apo A-I mRNA abundance. EPA reduced cellular triacylglycerol labeling by one-half, and DHA and EPA decreased cellular phospholipid labeling compared with OA. Labeled triacylglycerol secretion was decreased 75% by EPA, and DHA doubled labeled phospholipid secretion. If present in vivo, these effects should be considered before supplementing infant formula with these fatty acids.

To examine the risk of mortality following all clinical fractures, we followed 6459 women age 55-81 years participating in the Fracture Intervention Trial for an average of 3.8 years. All fractures and deaths were confirmed by medical record or death certificate. Clinical fractures were fractures that came to medical attention. Fracture status was used as a time-dependent covariate in proportional hazards models. The 907 women who experienced a fracture were older, had lower bone mineral density and were more likely to report a positive fracture history. A total of 122 women died over the course of the study with 23 of these deaths occurring after a clinical fracture. The age-adjusted relative risk (95% confidence intervals) of dying following a clinical fracture was 2.15 (1.36, 3.42). This primarily reflected the higher mortality following a hip fracture, 6.68 (3.08, 14.52); and clinical vertebral fracture, 8.64 (4.45, 16.74). Results were similar after adjusting for treatment assignment, health status and specific common comorbidities. There was no increase in mortality following a forearm or other fracture (non-hip, non-wrist, nonvertebral fracture). In conclusion, clinical vertebral fractures and hip fractures are associated with a substantial increase in mortality among a group of relatively healthy older women.

Biliary lipids, composed of bile acids, cholesterol, and phosphatidylcholine, are a major source of luminal lipid in the small intestine. In the present study in a newborn swine intestinal epithelial cell line (IPEC-1), taurocholate and phosphatidylcholine were found to have no effect on apolipoprotein B (apo B) secretion but did significantly increase the basolateral secretion of apo A-I. This regulation of apo A-I secretion occurred at the pretranslational level for taurocholate and at the posttranslational level for phosphatidylcholine. The regulation of apo A-I secretion by phosphatidylcholine did not involve changes in apo A-I degradation and may involve mobilization of a preformed pool of apo A-I. Cholesterol, whether solubilized with taurocholate or phosphatidylcholine, had no effect on the secretion of either apo B or apo A-I. However, when taurocholate, phosphatidylcholine, and cholesterol were combined, apo B secretion was decreased, and the increase in apo A-I secretion noted with taurocholate and phosphatidylcholine alone was ablated. Another primary bile acid, taurochenodeoxycholate, was found to decrease apo B secretion but had no effect on apo A-I secretion. However, the significance of this effect is uncertain, since this bile acid caused significant cellular membrane injury, as evidenced by increased apical medium lactate dehydrogenase activity. Phosphatidylcholine, but not taurocholate, dramatically increased the basolateral secretion of radiolabeled phospholipid with a modest increase in cellular triglyceride radiolabeling. Furthermore, this effect of phosphatidylcholine on lipid synthesis did not require significant hydrolysis or uptake of the phosphatidylcholine molecule. Studies using radiolabeled taurocholate did not demonstrate active transport of taurocholate by these cells.

The purpose of this study was to determine the effect of chronic (1 wk) feeding of dietary triacylglycerol (TG) of varying fatty acid composition on small intestinal and hepatic apolipoprotein expression, as well as serum lipid and apolipoprotein concentrations, in newborn swine. Two-day-old female swine were fed one of three diets by gavage with the following lipid composition: medium-chain TG (MCT; MCT oil), intermediate-chain saturated TG (ICST; coconut oil), and long-chain polyunsaturated TG (LCPUT; safflower oil) at 753 kJ ⋅ kg−1⋅ day−1with 51% of energy from fat. After 1 wk, serum lipids and apolipoprotein concentrations were measured, and jejunal apolipoprotein B (apo B) and apo A-I mass and apo B, apo A-I, apo A-IV, and apo C-III synthesis were measured. Liver was processed for determination of apo B and apo A-I mass and apo B, apo A-I, apo C-III, and β-actin mRNA abundance by slot blot hybridization. Compared with the MCT and LCPUT groups, the ICST group had higher total serum cholesterol, TG, high-density lipoprotein (HDL)-cholesterol, and apo A-I concentrations. There were no differences among the three groups for intestinal apolipoprotein mass or synthesis. In liver, apo A-I mass was highest in the ICST group. Liver apo A-I and apo C-III mRNA abundance was highest in the ICST group. Among all three groups, hepatic apo A-I mass correlated significantly with plasma HDL-cholesterol concentrations, and serum TG concentrations correlated with hepatic apo C-III mRNA abundance. In conclusion, we found that in the newborn piglet, chronic feeding of ICST increases serum total cholesterol, TG, HDL-cholesterol, and apo A-I concentrations and hepatic expression of apo A-I and apo C-III mRNA, compared with feeding of MCT or LCPUT. We speculate that increased hepatic apo A-I expression may contribute to the higher serum HDL and apo A-I concentrations in the ICST animals. Increased hepatic expression of apo C-III with ICST feeding may contribute to the higher serum TG concentrations by apo C-III-mediated inhibition of the catabolism of triacylglycerol-rich lipoproteins.

The aim of these studies was to characterize the synthesis and secretion of lipoproteins and apolipoprotein B (apo B) and apo A-I by a newborn swine intestinal epithelial cell line (IPEC-1). Differentiated cells exhibited enterocytic features, including microvilli. [3H] oleic acid was taken up and incorporated into cellular lipids and secreted into the basolateral medium in lipoproteins. Total apo B and apo A-I secreted increased with oleic acid incubation. However, cellular apo B and apo A-I content did not change. Whereas undifferentiated cells synthesized and secreted only apo B-100, both apo B-100 and apo B-48 were produced by differentiated cells. The ratio of radiolabeled apo B-48 to apo B-100 in both basolateral medium and cell homogenate increased with oleic acid treatment after 24-h steady-state labeling. However, apo B mRNA editing was unchanged, indicating posttranslational regulation of this ratio. Pulse-chase radiolabeling demonstrated no major changes in cellular or basolateral medium apolipoprotein labeling kinetics with oleic acid or dexamethasone incubation. The dissociation of apo B and apo A-I mass secretion from the secretion of radiolabeled apo B and apo A-I in response to oleic acid absorption suggests the presence of an intracellular pool of apolipoprotein with a slow turnover that is mobilized for secretion in response to fatty acid uptake.

The purpose of this study was to determine the effects of dietary fatty acids of varying chain lengths and degrees of saturation on intestinal apolipoprotein (apo) B and A-I expression in the newborn piglet. Two-day-old female piglets received one of three isocaloric formulas containing 48% of total calories (120 kcal/kg/24 h) as medium-chain triglycerides (MCT) from MCT oil, intermediate-chain saturated triglycerides (ICST) from coconut oil, or long-chain polyunsaturated triglycerides (LCPUT) from safflower oil by continuous duodenal infusion for 24 h. After in situ radiolabeling, jejunal and ileal mucosal apo B-48 and A-I were immunoprecipitated, and synthesis was expressed as percentage of total protein synthesis. Mucosal apo B and A-I mass was measured by ELISA as nanograms of apoprotein/microgram of total protein. Fifty percent less apo B jejunal synthesis was present in the ICST group versus the MCT and LCPUT groups (0.67 +/- 0.07, 1.19 +/- 0.20, and 1.25 +/- 0.15, respectively, mean +/- SEM, p0.05). Jejunal apo B mass was lower in the MCT group versus the ICST and LCPUT groups (0.10 +/- 0.02, 0.21 +/- 0.03, and 0.16 +/- 0.03, respectively, p0.05). Ileal apo B synthesis was lowest in the ICST group. No differences were found in ileal apo B mass. Two-fold higher jejunal apo A-I synthesis was found in the LCPUT group versus the MCT and ICST groups (14.18 +/- 1.69, 7.56 +/- 2.63, and 6.36 +/- 0.58, respectively, p0.01). No differences were found for jejunal apo A-I mass. In the ileum, the only difference was a higher apo A-I mass in the LCPUT group (p0.05). We conclude that in the newborn piglet intestinal apo B and A-I expression is acutely and differentially regulated by dietary lipid varying in fatty acid chain length and saturation. The patterns of regulation are complex and vary among specific apolipoproteins and regions of the small intestine and include co- and posttranslational mechanisms.