Search

Improved accuracy in predicting coronary heart disease (CHD) risk in patients with diabetes and kidney disease is needed. The addition of albuminuria to established methods of CHD risk calculation was reported in the Strong Heart Study (SHS) cohort. In this study, the addition of estimated glomerular filtration rate (eGFR) was evaluated using data from 4,549 American Indian SHS participants aged 45 to 74 years. After adjustment for Framingham CHD risk factors, hazard ratios for eGFR as a predictor of CHD were 1.69 (95% confidence interval 1.34 to 2.13) in women and 1.41 (95% confidence interval 0.94 to 2.13) in men. Models including albuminuria, eGFR, or both scored higher in discriminatory power than models using conventional risk factors alone in women; in men, the improvement was seen only for albuminuria and the combination of albuminuria and eGFR. Hosmer-Lemeshow assessments showed good calibration for the models using eGFR alone in both genders, followed by models including albuminuria alone in both genders. Adding eGFR improved the net reclassification improvement (NRI) in women (0.085, p = 0.0004) but not in men (0.010, p = 0.1967). NRI and integrated discrimination improvement (IDI) were improved in both genders using albuminuria and eGFR (NRI 0.135, p <0.0001, and IDI 0.027, p <0.0001 in women; NRI 0.035, p <0.0196, and IDI 0.008, p <0.0156 in men). Therefore, a risk calculator including albuminuria enhances CHD prediction compared to a calculator using only standard risk factors in men and women. Including eGFR alone improves risk prediction in women, but for men, it is preferable to include eGFR and albuminuria. In conclusion, this enhanced calculator should be useful in estimating CHD risk in populations with high prevalence of diabetes and renal disease., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To identify genetic variation influencing serum bilirubin levels in American Indians, we performed genome-wide screening and association analyses in the Strong Heart Family Study. Bilirubin is an endogenous antioxidant that has demonstrated an inverse relationship with cardiovascular disease. Genetic variation within the promoter region of uridine diphosphate glucuronosyltransferase (UGT1A1) on chromosome 2q has been associated with elevated serum bilirubin levels in European populations. However, no study has investigated the UGT1A1 promoter in American Indians., Methods: Statistical analyses were carried out with 3,484 participants aged 14 to 93 years recruited from three geographic areas in the United States; Arizona, Oklahoma, and North and South Dakota., Results: Variance components linkage analysis detected a quantitative trait locus (QTL) for bilirubin on chromosome 2q in the combined centers (LOD = 6.61, P = 4.24 × 10⁻⁶) and in Oklahoma (LOD = 5.65, P = 4.57 24 × 10⁻⁵). Genetic association of the UGT1A1 promoter polymorphism was significant for all geographic locations. After adjustment using conditional linkage for UGT1A1 promoter variance, the linkage signal dropped to 1.10 in the combined sample and to 3.32 (P = 0.02) in Oklahoma, indicating this polymorphism is not completely responsible for the linkage signal in American Indians. We also detected suggestive linkage signals in the Dakotas on chromosome 10p12 (LOD = 2.18) and in the combined centers (LOD = 2.24) on chromosome 10q21., Conclusions: Replication of a serum bilirubin QTL on chromosome 2q in American Indians implicates UGT1A1 but further genotyping is warranted to identify additional causative polymorphisms. Evidence also supports a potential novel locus for bilirubin on chromosome 10., (© 2010 Wiley-Liss, Inc.)

Objective: To evaluate the effectiveness of Diclectin (doxylamine succinate 10 mg-pyridoxine hydrochloride 10 mg, delayed-release preparation) as compared with placebo for nausea and vomiting of pregnancy., Study Design: A randomized, double-blind, multicenter placebo controlled trial studying pregnant women suffering from nausea and vomiting of pregnancy, analyzed by intention to treat. Women received Diclectin (n = 131) or placebo (n = 125) for 14 days. Nausea and vomiting of pregnancy symptoms were evaluated daily using the pregnancy unique quantification of emesis scale., Results: Diclectin use resulted in a significantly larger improvement in symptoms of nausea and vomiting of pregnancy compared with placebo based on both the pregnancy unique quantification of emesis score (-4.8 ± 2.7 vs -3.9 ± 2.6; P = .006) and quality of life. After the trial, 64 (48.9%) women receiving Diclectin asked to continue compassionate use of their medication, as compared with 41 (32.8%) of placebo-treated women (P = .009)., Conclusion: Diclectin delayed release formulation of doxylamine succinate and pyridoxine hydrochloride is effective and well tolerated in treating nausea and vomiting of pregnancy., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Background: The association between prediabetes as currently defined and incident diabetes in populations with widespread obesity, insulin resistance syndrome, and diabetes is not well defined. In this article, diabetes risk factors and incidence rates in American Indians (AI) with prediabetes are examined., Methods: A total of 1677 AI who were nondiabetic at baseline was examined during a median 7.8-year follow-up as part of the Strong Heart Study (SHS). Risk factors for incident diabetes were measured. Prediabetes was defined according to American Diabetes Association 2003 criteria as having impaired glucose tolerance (IGT) (2-h plasma glucose [2-h PG] >or= 140 mg/dL but < 200 mg/dL) and/or impaired fasting glucose (IFG) (fasting plasma glucose [FPG] >or= 100 mg/dL but < 126 mg/dL)., Results: Prediabetes was identified by FPG alone in 87.5%. Diabetes incidence in those with baseline prediabetes was 66.1/1000 person-years, with a hazard ratio (HR) of 2.35 (95% conference interval: 1.84-3.01), compared with participants with normal glucose tolerance (NGT) at baseline. Elevated A(1c), 2-h PG, and fasting insulin (FI); albuminuria; and obesity were significantly associated with conversion from prediabetes to diabetes. Younger age, elevated FI (or body mass index [BMI] in models without FI), and less physical activity were significantly associated with conversion from NGT., Conclusions: Prediabetes is an independent predictor of conversion to type 2 diabetes in AI, and most can be identified through a fasting glucose measure. Measures of obesity, A(1c), FPG, 2-h PG, FI, albuminuria, and insulin resistance (IR) help predict this conversion. Obesity is a modifiable risk factor. Strategies to reduce obesity should be emphasized in individuals with prediabetes., (Copyright (c) 2010 John Wiley & Sons, Ltd.)

Background and Aims: Although Eskimos were thought to be protected from cardiovascular disease (CVD), state health data show a large proportion of deaths from CVD, despite traditional lifestyles and high omega-3 fatty acid intake. This article explores CVD prevalence and its relation to risk factors in Alaska Eskimos., Methods and Results: A population-based cohort of 499 Alaska Eskimos > age 45 from the Norton Sound region was examined in 2000-2004 for CVD and associated risk factors as part of the Genetics of Coronary Artery Disease in Alaska Natives study. CVD and atherosclerosis were evaluated and adjudicated using standardized methods. Average age was 58 years; diabetes prevalence was low and high-density lipoprotein cholesterol (HDL-C) concentrations were high, but a large proportion smoked and had high pathogen burden. CVD was higher in men (12.6%) than in women (5.3%) (prevalence ratio 2.4, CI 1.3-4.4). Rates of stroke (6.1% in men, 1.8% in women) were similar to those for coronary heart disease (CHD) (6.1% men, 2.5% women). MI prevalence was low in both genders (1.9% and 0.7%). CVD was higher in men and in those >60 years. Hypertension, diabetes, high LDL-C, high apoB, and low HDL-C were all strong correlates (<.002) and albuminuria and CRP were also correlated with CVD (p<.05) after adjustment for age and gender. Carotid atherosclerosis was correlated with CVD (p=.0079) independent of other risk factors., Conclusion: These data show high CHD and stroke prevalence in Alaska Eskimos, despite low average LDL-C and high HDL-C. Hypertension and high LDL-C were independent correlates; identifying these risk factors early and treating to target is recommended.

Our objective was to evaluate the pharmacokinetics of metformin during pregnancy. Serial blood and urine samples were collected over one steady-state dosing interval in women treated with metformin during early to late pregnancy (n = 35) and postpartum (n = 16). Maternal and umbilical cord blood samples were obtained at delivery from 12 women. Metformin concentrations were also determined in breast milk samples obtained over one dosing interval in 6 women. Metformin renal clearance increased significantly in mid (723 +/- 243 ml/min, P < 0.01) and late pregnancy (625 +/- 130 ml/min, P < 0.01) compared with postpartum (477 +/- 132 ml/min). These changes reflected significant increases in creatinine clearance (240 +/- 70 ml/min, P < 0.01 and 207 +/- 56 ml/min, P < 0.05 versus 165 +/- 44 ml/min) and in metformin net secretion clearance (480 +/- 190 ml/min, P < 0.01 and 419 +/- 78 ml/min, P < 0.01 versus 313 +/- 98 ml/min) in mid and late pregnancy versus postpartum, respectively. Metformin concentrations at the time of delivery in umbilical cord plasma ranged between nondetectable (<5 ng/ml) and 1263 ng/ml. The daily infant intake of metformin through breast milk was 0.13 to 0.28 mg, and the relative infant dose was <0.5% of the mother's weight-adjusted dose. Our results indicate that metformin pharmacokinetics are affected by pregnancy-related changes in renal filtration and net tubular transport and can be roughly estimated by the use of creatinine clearance. At the time of delivery, the fetus is exposed to metformin concentrations from negligible to as high as maternal concentrations. In contrast, infant exposure to metformin through the breast milk is low.

Chronic kidney disease (CKD) is an important public health problem in American Indian populations. Recent research has identified associations of polymorphisms in the myosin heavy chain type II isoform A (MYH9) gene with hypertensive CKD in African-Americans. Whether these associations are also present among American Indian individuals is unknown. To evaluate the role of genetic polymorphisms in the MYH9 gene on kidney disease in American Indians, we genotyped 25 SNPs in the MYH9 gene region in 1,119 comparatively unrelated individuals. Four SNPs failed, and one SNP was monomorphic We inferred haplotypes using seven SNPs within the region of the previously described E haplotype using Phase v2.1. We studied the association between 20 MYH9 SNPs with kidney function (estimated glomerular filtration rate, eGFR) and CKD (eGFR\60 ml/min/1.73 m(2) or renal replacement therapy or kidney transplant) using age-, sex- and center-adjusted models and measured genotyped within the variance component models. MYH9 SNPs were not significantly associated with kidney traits in additive or recessive genetic adjusted models. MYH9 haplotypes were also not significantly associated with kidney outcomes. In conclusion, common variants in MYH9 polymorphisms may not confer an increased risk of CKD in American Indian populations. Identification of the actual functional genetic variation responsible for the associations seen in African-Americans will likely help to clarify the lack of replication of this gene in our population of American Indians.

Background: The prevalence and associated risk factors for albuminuria and low-grade albuminuria in Alaska Natives is not known., Methods: Cross-sectional analysis of the Genetics of Coronary Artery Disease in Alaska Natives Study. We included 1,026 individuals, who represent 85% of the study participants for whom complete data were available. Risk factors examined were age, sex, education, diabetes, hypertension, obesity, lipids, C-reactive protein, angiotensin-converting enzyme inhibitor use, and smoking status. Urine albumin excretion was estimated by the albumin/creatinine ratio measured from a single random morning urine sample. Albuminuria was defined as an albumin/creatinine ratio of > or =30 mg/g. Low-grade albuminuria was defined as an albumin/creatinine ratio of 10 to <30 mg/g., Results: The mean age was 42 years and over half were female. Diabetes prevalence was low at 3% and the prevalence of hypertension was 20%. The prevalence of albuminuria was 6%; the prevalence of low-grade albuminuria was 12%. Individuals with diabetes or hypertension were 3 times more likely to have albuminuria than those without these conditions [odd ratios: diabetes 3.0 (1.2-7.9) and hypertension 3.0 (1.2-7.3)]., Conclusions: The burden of albuminuria is low. Comprehensive programs and policies are important given the rise in diabetes and hypertension among Alaska Natives., (Copyright 2010 S. Karger AG, Basel.)

This article describes a 'Mastery Rubric' (MR) used to design both the curriculum and the assessments in a new two-year certificate programme intended to train physicians in clinical research skills. The MR for clinical research skills is built around a set of core research skills: critical review of literature; articulation of research objective; development of research design; development of analysis plan; implementation of the study; implementation of the analysis plan and presentation of results. Four distinct levels of performance are described for each skill: beginning, novice, competent and proficient. This rubric outlines and provides a path to mastery of the clinical research skills the certificate programme was designed and funded to target. Using the rubric to design the curriculum ensures that courses will provide instruction in key domains, promotes assessment that demonstrates development in the target skills and knowledge, and encourages reflection and cognitive self-monitoring in the students. It is a flexible, criterion-referenced definition of 'success' for students as well as the programme itself. The criteria are characterised in terms of the skills, habits of mind and organisational principles that can foster excellence in clinical research, but the approach can be generalised.

Intermittent hemodialysis is the primary supportive therapy for patients with end-stage renal disease, who commonly receive several drugs to treat both their underlying disease and the conditions that arise during long-term hemodialysis therapy. Many of these drugs are dialyzable, and their hemodialytic removal may compromise therapeutic efficacy if appropriate supplementary doses are not given. Emergency hemodialysis may also be life-saving for patients who have received drug overdoses or have ingested toxic substances. Optimal therapy in both these clinical settings is critically dependent on the availability of reliable information from well-designed pharmacokinetic studies.

Hyperuricemia is associated with the metabolic syndrome, gout, renal and cardiovascular disease (CVD). American Indians have high rates of CVD and 25% of individuals in the strong heart family study (SHFS) have high serum uric acid levels. The aim of this study was to investigate the genetic determinants of serum uric acid variation in American Indian participants of the SHFS. A variance component decomposition approach (implemented in SOLAR) was used to conduct univariate genetic analyses in each of three study centers and the combined sample. Serum uric acid was adjusted for age, sex, age x sex, BMI, estimated glomerular filtration rate, alcohol intake, diabetic status and medications. Overall mean +/- SD serum uric acid for all individuals was 5.14 +/- 1.5 mg/dl. Serum uric acid was found to be significantly heritable (0.46 +/- 0.03 in all centers, and 0.39 +/- 0.07, 0.51 +/- 0.05, 0.44 +/- 0.06 in Arizona, Dakotas and Oklahoma, respectively). Multipoint linkage analysis showed significant evidence of linkage for serum uric acid on chromosome 11 in the Dakotas center [logarithm of odds score (LOD) = 3.02] and in the combined sample (LOD = 3.56) and on chromosome 1 (LOD = 3.51) in the combined sample. A strong positional candidate gene in the chromosome 11 region is solute carrier family22, member 12 (SLC22A12) that encodes a major uric acid transporter URAT1. These results show a significant genetic influence and a possible role for one or more genes on chromosomes 1 and 11 on the variation in serum uric acid in American Indian populations.

The Stop Atherosclerosis in Native Diabetics Study (SANDS) was a randomized open-label clinical trial in type 2 diabetics designed to examine the effects of intensive reduction of blood pressure, aggressive vs standard goals (< or =115/75 mm Hg vs < or =130/80 mm Hg), and low-density lipoprotein (LDL) cholesterol on the composite outcome of change in carotid intimal-medial thickness and cardiovascular events. The study demonstrated that in conjunction with a lower LDL cholesterol target of 70 mg/dL, aggressive systolic blood pressure-lowering resulted in a reduction in carotid intimal-medial thickness and left ventricular mass without measurable differences in cardiovascular events. The blood pressure treatment algorithm included renin-angiotensin system blockade, with other agents added if necessary. The authors conclude that both standard and more aggressive systolic blood pressure reduction can be achieved with excellent safety and good tolerability in patients with type 2 diabetes mellitus.

BACKGROUND: Lowering low-density lipoprotein cholesterol (LDL-C) with statins reduces atherosclerosis. LDL and high-density lipoprotein (HDL) are commonly measured by their cholesterol content, but non-HDL cholesterol, LDL particle number (LDL-P), or total apolipoprotein B (apoB) may better predict cardiovascular risk. Few studies have examined relations among lipoprotein levels and composition before and after interventions to lower LDL-C and non-HDL-C. OBJECTIVE: To measure changes in carotid artery intimal media thickness (CIMT) and lipid concentration and composition during 36 months of statin therapy. METHODS: Analyses were conducted on 418 diabetic individuals, with complete data and no prior cardiovascular events, who were randomized to aggressive (AG) versus standard (STD) treatment for LDL-C, non-HDL-C, and systolic blood pressure (SBP) as part of the Stop Atherosclerosis in Native Diabetics Study (SANDS). RESULTS: The AG group achieved average LDL-C and non-HDL-C of 71mg/dL and 100mg/dL and a decrease in CIMT. No significant interactions were observed between treatment effect and initial levels of LDL-C, non-HDL-C, HDL-C, triglycerides, apoB, or LDL-P. Decreases in LDL-C (p<.005) and non-HDL-C (p<.001) were independently correlated with CIMT regression in the AG group. Changes in apoB and LDL-P showed borderline correlations with CIMT regression (p=.07 and p=.09). CONCLUSIONS: In diabetic adults with no prior cardiovascular events, treatment to current targets for lipids and SBP reduces atherosclerosis progression and when more aggressive targets are met, atherosclerosis regresses. The aggressive targets for LDL-C and non-HDL-C appeared to be the main determinants of CIMT regression and were more predictive of this outcome than changes in LDL-P or apoB.

Background: Arsenic exposure in drinking water disproportionately affects small communities in some U.S. regions, including American Indian communities. In U.S. adults with no seafood intake, median total urine arsenic is 3.4 microg/L., Objective: We evaluated arsenic exposure and excretion patterns using urine samples collected over 10 years in a random sample of American Indians from Arizona, Oklahoma, and North and South Dakota who participated in a cohort study from 1989 to 1999., Methods: We measured total urine arsenic and arsenic species [inorganic arsenic (arsenite and arsenate), methylarsonate (MA), dimethylarsinate (DMA), and arsenobetaine] concentrations in 60 participants (three urine samples each, for a total of 180 urine samples) using inductively coupled plasma/mass spectrometry (ICPMS) and high-performance liquid chromatography/ICPMS, respectively., Results: Median (10th, 90th percentiles) urine concentration for the sum of inorganic arsenic, MA, and DMA at baseline was 7.2 (3.1, 16.9) microg/g creatinine; the median was higher in Arizona (12.5 microg/g), intermediate in the Dakotas (9.1 microg/g), and lower in Oklahoma (4.4 microg/g). The mean percentage distribution of arsenic species over the sum of inorganic and methylated species was 10.6% for inorganic arsenic, 18.4% for MA, and 70.9% for DMA. The intraclass correlation coefficient for three repeated arsenic measurements over a 10-year period was 0.80 for the sum of inorganic and methylated species and 0.64, 0.80, and 0.77 for percent inorganic arsenic, percent MA, and percent DMA, respectively., Conclusions: This study found low to moderate inorganic arsenic exposure and confirmed long-term constancy in arsenic exposure and urine excretion patterns in American Indians from three U.S. regions over a 10-year period. Our findings support the feasibility of analyzing arsenic species in large population-based studies with stored urine samples.

Background: Population studies have demonstrated an important role of social, behavioral, and environmental factors in blood pressure (BP) levels. Accounting for the genetic interaction of these factors may help to identify common BP susceptibility alleles., Methods and Results: We studied the interaction of additive genetic effects and behavioral (physical activity, smoking, alcohol use) and socioeconomic (education) factors on BP in approximately 3600 American Indian participants of the Strong Heart Family Study, using variance component models. The mean and SD of resting systolic and diastolic BPs were 123 + or - 17 and 76 + or - 11 mm Hg, respectively. We detected evidence for distinct genetic effects on diastolic BP among ever smokers compared with never smokers (P = 0.01). For alcohol intake, we observed significant genotype-by-environment interactions on diastolic (rhog = 0.10, P = 0.0003) and on systolic BPs (rhog = 0.59, P = 0.0008) among current drinkers compared with former or never drinkers. We also detected genotype-by-physical activity interactions on diastolic BP (rhog = 0.35, P = 0.0004). Finally, there was evidence for distinct genetic effects on diastolic BP among individuals with less than high school education compared with those with 12 or more years of education (rhog = 0.41, P = 0.02)., Conclusions: Our findings suggest that behavioral and socioeconomic factors can modify the genetic effects on BP phenotypes. Accounting for context dependent factors may help us to better understand the complexities of the gene effects on BP and other complex phenotypes with high levels of genetic heterogeneity.

Several biomarkers have been documented, singly or jointly, to improve risk prediction, but the extent to which they improve prediction-model performance in populations with high prevalences of obesity and diabetes has not been specifically examined. The aim of this study was to evaluate the ability of various biomarkers to improve prediction-model performance for death and major cardiovascular disease (CVD) events in a high-risk population. The relations of 6 biomarkers with outcomes were examined in 823 American Indians free of prevalent CVD or renal insufficiency, as were their contributions to risk prediction. In single-marker models adjusting for standard clinical and laboratory risk factors, 4 of 6 biomarkers significantly predicted mortality and major CVD events. In multimarker models, these 4 biomarkers-urinary albumin/creatinine ratio (UACR), glycosylated hemoglobin, B-type natriuretic peptide, and fibrinogen-significantly predicted mortality, while 2-UACR and fibrinogen-significantly predicted CVD. On the basis of its robust association in participants with diabetes, UACR was the strongest predictor of mortality and CVD, individually improving model discrimination or classification in the entire cohort. Singly, all remaining biomarkers also improved risk classification for mortality and enhanced average sensitivity for mortality and CVD. The addition of > or =1 biomarker to the single marker UACR further improved discrimination or average sensitivity for these outcomes. In conclusion, biomarkers derived from diabetic cohorts, and novel biomarkers evaluated primarily in lower risk populations, improve risk prediction in cohorts with prevalent obesity and diabetes. Risk stratification of these populations with multimarker models could enhance selection for aggressive medical or surgical approaches to prevention.

American Indians have a higher prevalence of albuminuria than the general population, likely resulting from a combination of environmental and genetic risk factors. To localize gene regions influencing variation in urinary albumin-to-creatinine ratio, we performed a linkage analysis and explored gene-by-diabetes, -hypertension, and -obesity interactions in a large cohort of American Indian families. We recruited >3600 individuals from 13 American Indian tribes from three centers (Arizona, North and South Dakota, and Oklahoma). We performed multipoint variance component linkage analysis in each center as well as in the entire cohort after controlling for center effects. We used two modeling strategies: Model 1 incorporated age, gender, and interaction terms; model 2 also controlled for diabetes, BP, body mass index, HDL, LDL, triglycerides, and smoking status. We evaluated interactions with diabetes, hypertension, and obesity using additive, interaction-specific linkage and stratified analyses. Loci suggestive for linkage to urinary albumin-to-creatinine ratio included 1q, 6p, 9q, 18q, and 20p. Gene-by-diabetes interaction was present with a quantitative trait locus specific to the diabetic stratum in the Dakotas isolated on 18q21.2 to 21.3 using model 1 (logarithm of odds = 3.3). Gene-by-hypertension interaction was present with quantitative trait loci specific to the hypertensive stratum in the Dakotas on 7q21.11 using model 1 (logarithm of odds = 3.4) and 10q25.1 using model 2 (logarithm of odds = 3.3). These loci replicate findings from multiple other genome scans of kidney disease phenotypes with distinct populations and are worthy of further study.

Background: Kidney function, expressed as glomerular filtration rate (GFR), is commonly estimated from serum creatinine (Scr) and, when decreased, may serve as a nonclassical risk factor for incident cardiovascular disease (CVD). The ability of estimated GFR (eGFR) to predict CVD events during 5-10 years of follow-up is assessed using data from the Strong Heart Study (SHS), a large cohort with a high prevalence of diabetes., Methods: eGFRs were calculated with the abbreviated Modification of Diet in Renal Disease study (MDRD) and the Cockcroft-Gault (CG) equations. These estimates were compared in participants with normal and abnormal Scr. The association between eGFR and incident CVD was assessed., Results: More subjects were labeled as having low eGFR (<60 ml/min per 1.73 m2) by the MDRD or CG equation, than by Scr alone. When Scr was in the normal range, both equations labeled similar numbers of participants as having low eGFRs, although concordance between the equations was poor. However, when Scr was elevated, the MDRD equation labeled more subjects as having low eGFR. Persons with low eGFR had increased risk of CVD., Conclusions: The MDRD and CG equations labeled more participants as having decreased GFR than did Scr alone. Decreased eGFR was predictive of CVD in this American Indian population with a high prevalence of obesity and type 2 diabetes mellitus.

Objectives: This secondary analysis from the SANDS (Stop Atherosclerosis in Native Diabetics Study) trial examines the effects of lowering low-density lipoprotein cholesterol (LDL-C) with statins alone versus statins plus ezetimibe on common carotid artery intima-media thickness (CIMT) in patients with type 2 diabetes and no prior cardiovascular event., Background: It is unknown whether the addition of ezetimibe to statin therapy affects subclinical atherosclerosis., Methods: Within an aggressive group (target LDL-C 40 years of age receiving statins plus ezetimibe versus statins alone. The CIMT changes in both aggressive subgroups were compared with changes in the standard subgroups (target LDL-C

American Indians have a disproportionately high rate of kidney disease likely due to a combination of environmental and genetic factors. We performed a genome wide scan of estimated glomerular filtration rate in 3665 participants of the Strong Heart Family Study to localize genes influencing kidney disease risk factors. The participants were men and women from 13 American Indian tribes recruited from 3 centers located in Arizona, the Dakotas and Oklahoma. Multipoint variance component linkage analysis was performed for each center and on the entire cohort after controlling for center effects. Modeling strategies that incorporated age, gender and interaction terms (model 1) and another that also controlled for diabetes mellitus, systolic and diastolic blood pressure, body mass index, low density and high density lipoproteins, triglycerides and smoking status (model 2) were used. Significant evidence for linkage in the Arizona group was found on chromosome 12p12.2 at 39cM (nearest marker D12S310) using model 1. Additional loci with very suggestive evidence for linkage were detected at 1p36.31 for all groups using both models and at 2q33.3 and 9q34.2 for the Dakotas group each using model 1. No significant evidence for additive interaction with diabetes, hypertension or obesity was noted. This evidence for linkage of a quantitative trait locus influencing estimated glomerular filtration rate to a region of chromosome 12p in a large cohort of American Indians will be worth studying in more detail in the future.

Background: The pathogenesis of atherosclerosis involves both hemostatic and inflammatory mechanisms. Fibrinogen is associated with both risk of thrombosis and inflammation. A recent meta-analysis showed that risk of coronary heart disease may increase 1.8 fold for 1 g/L of increased fibrinogen, independent of traditional risk factors. It is known that fibrinogen levels may be influenced by demographic, environmental and genetic factors. Epidemiologic and candidate gene studies are available; but few genome-wide linkage studies have been conducted, particularly in minority populations. The Strong Heart Study has demonstrated an increased incidence of cardiovascular disease in the American Indian population, and therefore represents an important source for genetic-epidemiological investigations., Methods: The Strong Heart Family Study enrolled over 3,600 American Indian participants in large, multi-generational families, ascertained from an ongoing population-based study in the same communities. Fibrinogen was determined using standard technique in a central laboratory and extensive additional phenotypic measures were obtained. Participants were genotyped for 382 short tandem repeat markers distributed throughout the genome; and results were analyzed using a variance decomposition method, as implemented in the SOLAR 2.0 program., Results: Data from 3535 participants were included and after step-wise, linear regression analysis, two models were selected for investigation. Basic demographic adjustments constituted model 1, while model 2 considered waist circumference, diabetes mellitus and postmenopausal status as additional covariates. Five LOD scores between 1.82 and 3.02 were identified, with the maximally adjusted model showing the highest score on chromosome 7 at 28 cM. Genes for two key components of the inflammatory response, i.e. interleukin-6 and "signal transducer and activator of transcription 3" (STAT3), were identified within 2 and 8 Mb of this 1 LOD drop interval respectively. A LOD score of 1.82 on chromosome 17 between 68 and 93 cM is supported by reports from two other populations with LOD scores of 1.4 and 1.95., Conclusion: In a minority population with a high prevalence of cardiovascular disease, strong evidence for a novel genetic determinant of fibrinogen levels is found on chromosome 7 at 28 cM. Four other loci, some of which have been suggested by previous studies, were also identified.

Brachial blood pressure is predictive of cardiovascular outcome; however central pressure may better represent the load imposed on the coronary and cerebral arteries and thereby bear a stronger relationship to vascular damage and prognosis. Relations of brachial and central pressures to carotid artery hypertrophy (intimal-medial thickness and vascular mass), extent of atherosclerosis (plaque score), and incident cardiovascular events were examined in the Strong Heart Study. Central pressures were calculated using radial applanation tonometry. Among 3520 participants, central and brachial pulse pressures were more strongly related to vascular hypertrophy and extent of atherosclerosis than were systolic pressures. Central pulse pressure was more strongly related to all 3 arterial measures than was brachial pulse pressure (r=0.364 versus 0.309 for plaque score; P<0.001 for comparison of Spearman correlation coefficient; r=0.293 versus 0.249 for intimal-medial thickness; P<0.002; r=0.320 versus 0.289 for vascular mass; P<0.05). Among the 2403 participants free of clinical cardiovascular disease at baseline, 319 suffered fatal or nonfatal cardiovascular events during mean follow-up of 4.8+/-1.3 years. After adjustment for age, gender, current smoking, body mass index, cholesterol:HDL ratio, creatinine, fibrinogen, diabetes, and heart rate, central pulse pressure predicted cardiovascular events more strongly than brachial pulse pressure (hazards ratio=1.15 per 10 mm Hg, chi(2)=13.4, P<0.001 versus hazards ratio=1.10, chi(2)=6.9, P=0.008). In conclusion, noninvasively-determined central pulse pressure is more strongly related to vascular hypertrophy, extent of atherosclerosis, and cardiovascular events than is brachial blood pressure. These findings support prospective examination of use of central blood pressure as a treatment target in future trials.

Missing data are a common problem in epidemiologic studies. This study had two aims: (a) to determine which method for imputing missing renal function data provides estimates closest to those made with complete data and (b) to determine which measure of renal function better estimates cardiovascular disease (CVD) risk. For these analyses, a subset of Strong Heart Study participants with complete data for renal function was identified. Data were randomly dropped from this complete set at three rates: 30, 45, and 60%. Five common techniques for handling missing data were compared: imputation using the mean, adjacent value (AV), single imputation, multiple imputation, and listwise deletion. Differences between the imputed sets and the complete set were determined for each method. Imputation methods were used to fill in missing values for serum creatinine (Scr) in one model and estimated glomerular filtration rate (eGFR) in another. For both Scr and eGFR, the AV method provided the most favorable results in predicting CVD risk, regardless of the rate of missing data.

Use of prescription and nonprescription medications is common during pregnancy and is required in many women with underlying kidney disease or hypertension and in all with solid-organ allografts. Systematic assessment of drug safety during pregnancy is lacking, as are rigorous and comprehensive studies of pharmacokinetics and pharmacodynamics to guide drug selection and dosing across pregnancy. Renal and hepatic clearances of many drugs change markedly during pregnancy and pitfalls may complicate routine therapeutic monitoring of some drugs during pregnancy. However, available data and clinical experience allow reasonable strategies for selection and dosing of immunosuppressive agents in pregnant transplant recipients and of antihypertensive agents in women with mild or more severe hypertension complicating their pregnancies.

Sleep-disordered breathing (SDB) has been noted commonly in hemodialysis (HD) patients, but it is not known whether this is related directly to the treatment of kidney failure with HD or to the higher prevalence of obesity and older age. Forty-six HD patients were compared with 137 participants from the Sleep Heart Health Study (SHHS) who were matched for age, gender, body mass index (BMI), and race. Home unattended polysomnography was performed and scored using similar protocols. The study sample was 62.7 +/- 10.1 yr, was predominantly male (72%) and white (63%), and had an average BMI of 28 +/- 5.3 kg/m(2). The HD sample had a higher systolic BP (137 versus 121 mmHg; P < 0.01) and a higher prevalence of diabetes (33 versus 9%; P < 0.01) and cardiovascular disease (33 versus 13%; P < 0.01) compared with the SHHS sample. The HD group had significantly less sleep time (320 versus 379 min; P < 0.0001) but similar sleep efficiency. HD patients had a higher frequency of arousals per hour (25.1 versus 17.1; P < 0.0001) and apnea-hypopneas per hour (27.2 versus 15.2; P < 0.0001) and greater percentage of the total sleep time below an oxygen saturation of 90% (7.2 versus 1.8; P < 0.0001). HD patients were more likely to have severe SDB (>30 respiratory events per hour) compared with the SHHS sample (odds ratio 4.07; 95% confidence interval 1.83 to 9.07). There was a strong association of HD with severe SDB and nocturnal hypoxemia independent of age, BMI, and the higher prevalence of chronic disease. The potential mechanisms for the higher likelihood of SDB in the HD population must be identified to provide specific prevention and therapy.

Without strict glycemic control, diabetic pregnancies are frequently complicated by spontaneous abortion, stillbirth, or congenital malformation. Retrospective studies have been largely reassuring that pregnancy does not accelerate morbid outcomes in women with diabetic vascular disease. Improved outcomes of high-risk pregnancy in women with pregestational, type 1, or type 2 diabetes mellitus remain challenging, depending on a comprehensive and multidisciplinary team approach and extensive preconception counseling.

We hypothesized that prolonged angiotensin II (AngII) infusion would alter vascular reactivity by enhancing superoxide anion (O-.2) generation. Male C57BL/6 mice were infused with AngII at 400 ng/kg/min (n=16, AngII mice) or vehicle (n=16, sham mice) for 2 weeks via subcutaneous osmotic minipumps. Contraction and relaxation of mesenteric resistance vessels (MRVs) were assessed using a Mulvany-Halpern myograph. AngII infusion increased systolic blood pressure, MRV NADPH oxidase activity and expression of p22phox mRNA. Contraction to norepinephrine was unchanged, but AngII infusion increased contractile responses to AngII (41+/-5 vs. 10+/-4%, p<0.001) and endothelin-1 (ET-1; 95+/-10 vs. 70+/-9%, p<0.05), which was normalized by tempol (10(-4) M, a stable membrane-permeable superoxide dismutase mimetic) and ebselen [10(-5) M, a peroxynitrite (ONOO-) scavenger]. Endothelium removal enhanced MRV contraction to AngII and ET-1 in sham mice but blunted these contractile responses in AngII mice. Relaxation to ACh was impaired in AngII mice (60.1+/-8.8 vs. 83.2+/-3.5%, p<0.01), which normalized by tempol, whereas relaxation to sodium nitroprusside was similar in both groups. N-nitro-L-arginine (NNLA, a nitric oxide synthase inhibitor), partially inhibited acetylcholine relaxation of vessels from sham mice but not from AngII mice. The residual endothelium-dependent hyperpolarizing-factor-like relaxation was not different between groups. In conclusion,the AngII slow pressor response in mouse MRVs consisted of specific contractile hyperresponsiveness and impairment in the NO-mediated component of endothelium-dependent relaxation, which was mediated by O-.2 and ONOO- in the vascular smooth muscle cell., (Copyright (c) 2006 S. Karger AG, Basel.)

Treatment with radioactive iodine ((131)I) may be necessary for thyroid cancer or for hyperthyroidism in patients with end-stage renal disease who require hemodialysis. Because (131)I is cleared mainly by the kidneys in patients with normal renal function, many issues arise in patients who require (131)I treatment but who are on hemodialysis. This paper presents a case report of a patient on dialysis who required treatment with (131)I for thyroid cancer. We describe a mathematical model, which suggests that the treatment dose of (131)I for a patient with thyroid cancer on hemodialysis would be approximately 13%-28% of a typical empiric dose of (131)I for a patient with normal renal function. Also, we present a comprehensive review and discussion of the literature on patients who are receiving hemodialysis who were treated with (131)I for either thyroid cancer or hyperthyroidism. Using a multidisciplinary approach and special precautions, (131)I therapy can be administered safely and effectively for patients with thyroid cancer or hyperthyroidism who are receiving hemodialysis.

The benefits of antihypertensive therapy in pregnancy remain uncertain. Blood pressure control to prevent or correct severe hypertension can avert maternal target organ damage and may allow obstetricians to prolong pregnancy or avoid hospitalization. Several factors limit the conclusions derived from systematic review of the available studies, including failure to distinguish among women with preeclampsia, gestational hypertension, or whose hypertension antedated pregnancy. As well, the application of consensus guidelines is limited by the unfortunate tendency to measure blood pressure by use of oscillometric devices rather than auscultation. We review the basis for using specific antihypertensive drugs in pregnancy and highlight important shortcomings in therapeutic knowledge that should be addressed in future studies.

The hypothesis that O(2)(.-) enhances angiotensin II (AngII)-induced vasoconstriction and impairs acetylcholine-induced vasodilation of afferent arterioles (Aff) in AngII-induced hypertension was investigated. Rabbits (n = 6 per group) received 12 to 14 d of 0.154 M NaCl (Sham), subpressor AngII (60 ng/kg per min; AngII 60) or slow pressor AngII (200 ng/kg per min; AngII 200). Individual Aff were perfused in vitro at 60 mmHg. AngII 200 increased mean arterial pressure (mean +/- SD; 103 +/- 9 versus 73 +/- 6 mmHg; P < 0.01), plasma lipid peroxides (2.6 +/- 0.3 versus 2.0 +/- 0.3 nM; P < 0.05), renal cortical NADPH- and NADH-dependent O(2)(.-) generation, and Aff mRNA for p22(phox) 5-fold (P < 0.001) but decreased that for AT(1)-receptor 2.4-fold (P < 0.01). AngII 60 increased only NADH-dependent O(2)(.-) generation by renal cortex. Aff from AngII 200 rabbits had diminished acetylcholine relaxations (+50 +/- 4 versus +85 +/- 6%; P < 0.001), but these became similar in the presence of nitro-L-arginine (10(-4) M). Aff from AngII 60 and AngII 200 rabbits had unchanged norepinephrine contractions (10(-7) M) but significantly (P < 0.05) enhanced AngII contractions (10(-8) M: Sham -52 +/- 5 versus AngII 60 to 77 +/- 5 versus AngII 200 to 110 +/- 10%). The superoxide dismutase mimetic tempol (10(-4) M) moderated the AngII responses of Aff from AngII 200 rabbits to levels of AngII 60 rabbits (-64 +/- 7%). The AngII slow pressor response enhances renal cortical O(2)(.-) and p22(phox) expression. Increased O(2)(.-) generation in Aff mediates an impaired nitric oxide synthase-dependent endothelium-derived relaxing factor response and paradoxically enhances contractions to AngII despite downregulation of the mRNA for AT(1) receptors. A subpressor dose of AngII enhances Aff responses to AngII independent of O(2)(.-).

Background: Acetylcholine-induced endothelium-dependent relaxation in the renal afferent arteriole has been ascribed to nitric oxide, but the role of endothelium-derived hyperpolarizing factors (EDHFs) and 14,15-epoxyeicosatrienoic acid (14,15-EET) are unclear., Methods: Single afferent arterioles were dissected from kidney of normal rabbits and microperfused in vitro at 60 mm Hg. Vessels were preconstricted submaximally with norepinephrine (10(-8) mol/L). Relaxation was assessed following cumulative addition of ACh (10(-9) to 10(-4) mol/L) alone, or in the presence of indomethacin (to inhibit cyclooxygenase), Nw-nitro-L-arginine (L-NNA) (to inhibit nitric oxide synthase), methylene blue (to inhibit soluble guanylate cyclase), or a combination of L-NNA + methylene blue. To assess contributions by EDHF, studies were repeated with either apamin + charybdotoxin [to block Ca2+-activated K+ channels (KCa)] or with 40 mmol/L KCl. To asses the role of 14,15-EET, relaxations were evaluated in the presence of its competitive inhibitor 14,15-epoxyeicosa-5(Z)-enoic acid (14,15-EEZE)., Results: Relaxation by acetylcholine was abolished following endothelial denudation. It was unaffected by indomethacin but was inhibited 54%+/- 5% (P < 0.001) by L-NNA, 57%+/- 5% by methylene blue, and 60%+/- 4% by the combination of L-NNA plus methylene blue. Relaxation was inhibited further by KCl (80%+/- 6%) or by apamin + charybdotoxin (96%+/- 2%). 14,15-EEZE, alone, inhibited acetylcholine-induced relaxation by 29%+/- 3%, and by 80%+/- 5% in the presence of L-NNA., Conclusion: Acetylcholine-induced afferent arteriolar relaxation depends strongly on both nitric oxide, acting via soluble guanylate cyclase, and on an EDHF, likely 14,15-EET, acting via KCa.

Human pregnancy, normally characterized by systemic vasodilation and modest hypotension, can be complicated by underlying maternal hypertension and several unique hypertensive disorders, including pre-eclampsia. Although well-designed and adequately powered clinical trials are critically needed, there have been several recent meta-analyses of this large literature, along with consensus statements and treatment guidelines from three distinct multidisciplinary groups of clinicians and investigators. In this paper we review recent analyses and guidelines, advising on our current approach to antihypertensive therapy in pregnant women.

We sought to delineate contributions of nitric oxide (NO) and other mechanisms to impairment of contraction and endothelium-dependent relaxation following prolonged in vitro incubation, endotoxin and interleukin-1 exposure in isolated rat aorta. Responses from freshly-dissected (control) rings +/-endothelium were compared with those from rings incubated in sterile, antibiotic containing medium +/- E. Coli endotoxin (LPS, 100 microg/ml) +/- interleukin-1 (IL-1, 40 ng/ml) at 37 degrees C for 20-24 h. In some experiments, medium included dexamethasone (DEX, 1 microg/ml), cycloheximide (10 microg/ml), or N(G)-nitro-L-arginine (NNLA, 10(-4)M). After incubation, medium nitrite was measured. Incubation alone, without addition of inflammatory mediators, impaired contraction in an agonist-specific manner, by both NO-dependent and NO-independent mechanisms. Either LPS or IL-1 diminished contraction further, in a similarly heterogeneous manner. For example, contractions were changed in LPS-incubated endothelium-intact rings (vs. fresh controls) by -85%, +115%, -15%, -96%, and -37% for phenylephrine (PE), serotonin, prostaglandin F2alpha, angiotensin II, and U46619, respectively. NO synthase inhibition with NNLA either following, or during LPS incubation only partially normalized subsequent PE contractions, an effect which was smaller than that of DEX. Nitrite accumulation was inversely proportional to PE response, even though NO was not the sole mediator of LPS-impaired contraction. LPS and IL-1 nearly abolished ACh-induced relaxation, which was only mildly impaired by incubation alone. We conclude that prolonged incubation impaired vasoconstriction via both NO synthase induction and NO-independent mechanisms. LPS or IL-1 incubation impaired vasoconstriction further, primarily by NO-independent mechanisms. Moreover, vasoconstrictor responses following LPS varied with the agonist's ability to modulate endothelial NO release. These results are in accord with the failure of NO synthase inhibition to fully restore systemic vascular resistance indices in experimental endotoxemia or in hyperdynamic septic patients.

Objective: To compare connexin expression in omental resistance arteries from preeclamptic women and normal gravidas., Methods: Small arteries (approximately 200-400 microm i.d.) were dissected from omental fat biopsies, taken at cesarean delivery from normotensive and preeclamptic women. Vessels were frozen and homogenized, then connexin-43 protein was detected by Western blot and quantitated by comparison with alpha-actin., Results: Connexin-43 was detected in all specimens, primarily in its phosphorylated form. Abundance did not differ between vessels from preeclamptic and normotensive gravidas., Conclusions: Phasic activity in omental resistance vessels from preeclamptic women likely depends on abnormal genesis of an oscillatory signal rather than on more extensive gap junctional communication between vascular cells.

We reported previously that acetylcholine (ACh)-induced endothelium-dependent relaxation of rat mesenteric microvessels depended both on nitric oxide (NO) and on a charybdotoxin (CTX)-sensitive endothelium-derived hyperpolarizing vasodilator. Cytochrome P450 (CYP)-dependent arachidonic acid metabolites act in some systems as hyperpolarizing vasodilators. We sought to quantitate contributions of such metabolites to the CTX-sensitive component of ACh-induced vasodilation in isolated rat mesenteric resistance arteries. ACh relaxed these vessels nearly completely (93.3+/-1.2%, n = 71); cyclooxygenase inhibition with indomethacin did not diminish this response (94.3+/-11.4%, n = 9). NO synthase inhibition with Nitro-L-arginine (NNLA) reduced relaxation by 30% (n = 54, p<0.05). Pretreatment of vessels with CYP inhibitors, either clotrimazole (CTM) or 17-octadecynoic acid (17-ODYA), or with selective K+ channel inhibitors, either tetraethyammonium acetate (TEA) or CTX, each led to similar small reductions in maximal relaxation (17%, 22%, 16%, and 9% respectively, n = 3-6). Combined pretreatment with NNLA + either (CTM or 17-ODYA) or (TEA or CTX) each led to similar maximal relaxations (52.2+/-4.8%, 50.6+/-9.2, 37.6+/-8.6%, and 44.1+/-11.5%, respectively, n = 6-35; p<0.05 for NNLA+[CTM or TEA or CTX] vs NNLA alone). Combined pretreatment with NNLA+CTM+(CTX or TEA) led to similar maximal relaxations (43.0+/-7.3%, 43.7+/-15%, n = 6-11) that did not differ from values in vessels pretreated with either NNLA+CTM or NNLA+(CTX or TEA). We conclude that the ACh-induced vasodilation was insensitive to cyclooxygenase inhibition, partially sensitive to NO synthase inhibition, and that the K+ channel blockers TEA and CTX identified the same minor component of ACh relaxation as did the CYP inhibitor CTM.

Background: Losartan, an angiotensin II receptor antagonist, has been shown to decrease serum uric acid and to increase urinary excretion of uric acid., Methods: To determine if this effect can increase the risk of acute urate nephropathy, 63 hypertensive patients with thiazide-induced asymptomatic hyperuricemia (serum uric acid 7.0 to 12.0 mg/dl) were randomized double-blind to losartan 50 mg every day (q.d.), losartan 50 mg plus hydrochlorothiazide (HCTZ) 50 mg q.d., HCTZ 50 mg q.d., or placebo for three weeks. To potentiate the risk of crystal formation, patients received a 2 g/kg protein diet one day prior to each clinic visit on days 0 (baseline), 1, 7, and 21., Results: Adverse events typically associated with acute urate nephropathy, for example, flank pain, hematuria, or increased blood urea nitrogen/creatinine, were not reported. Uric acid excretion and urine pH increased four and six hours after losartan on day 1 compared with day 0. Dihydrogen urate, the primary risk factor for crystal formation, decreased at four and six hours on day 1 compared with day 0 associated with the concurrent rise in urine pH. Day 7 and 21 changes, compared with day 0, in uric acid excretion rate, urine pH, and dihydrogen urate with losartan were comparable to day 1 results but were not statistically significant. Serum uric acid was significantly reduced after 21 days of therapy with losartan., Conclusion: Losartan decreased serum uric acid and increased uric acid excretion without increasing urinary dihydrogen urate, the primary risk factor for acute urate nephropathy, during 21 days of dosing in hypertensive patients with thiazide-induced hyperuricemia.

Background: We hypothesized that endotoxin (LPS) would impair bradykinin (BK)-induced calcium (Ca2+) mobilization in aortic endothelial cells, perhaps due to cytotoxicity or via stimulation of nitric oxide (NO) synthesis. As well, we sought to define contributions of LPS-stimulated Ca2+ mobilization to these effects., Methods: LPS- or BK-induced increments of intracellular Ca2+ were assessed by microspectrofluorimetry with fura-2 in passaged bovine aortic endothelial cells. Time- and dose-dependent effects of LPS exposure (+/- inhibitors of NO or prostaglandin synthesis) on subsequent BK-induced Ca2+ mobilization and on attached cell counts were determined., Results: LPS (0.1 to 1.0 mg/ml) led to rapid increments of Ca2+, while Ca2+ responses were delayed following LPS (1 to 10 microg/ml) and lower doses were without effect. By contrast, LPS more potently (1.0 pg to 1.0 microg/ml) led to dose- and time-dependent impairment of subsequent BK-induced Ca2+ mobilization, with peak effect at four to six hours, persisting for at least 18 hours. This delayed effect on BK-response was unaltered by inhibition of either NO synthase or cyclooxygenase. The effect of LPS on BK-responsivity depended importantly on cell confluence, as it was not observed in subconfluent cells. By contrast, LPS-induced cell detachment, which was observed only at doses > or = 1.0 microg/ml, did not depend on confluence., Conclusions: Different mechanisms lead to endothelial cytotoxicity and to impaired BK-response following LPS. Only the former effect, occurring at higher doses, might depend on initial LPS-induced Ca2+ mobilization.

Previous studies in vivo or in isolated airway preparations have suggested that eosinophil-derived polycationic proteins enhance airway smooth muscle tone in an epithelium-dependent manner. We assessed the direct effects of activated human eosinophil supernatant, major basic protein (MBP), and polycationic polypeptides on basal and agonist-stimulated intracellular Ca2+ concentrations ([Ca2+]i) in cultured bovine tracheal smooth muscle (TSM) cells. A 1-h incubation of myocytes with activated eosinophil buffer resulted in a doubling of basal [Ca2+]i and increased responsivity to histamine compared with myocytes that were exposed to sham-activated eosinophil buffer. In addition, concentration-dependent acute transient increases and subsequent 1-h sustained elevations of basal [Ca2+]i were observed immediately after addition of MBP and model polycationic proteins. Finally, both peak and plateau [Ca2+]i responses to bradykinin addition were augmented significantly in cultured myocytes that had been exposed to low concentrations of MBP or model polycationic proteins but were inhibited at greater concentrations. This elevated [Ca2+]i to polycationic proteins was manifest in epithelium-denuded bovine TSM strips as concentration-dependent increased basal tone. We conclude that activated eosinophil supernatant, MBP, and other polycationic proteins have a direct effect on both basal and subsequent agonist-elicited Ca2+ mobilization in cultured TSM cells; TSM strips in vitro demonstrated, respectively, augmented and diminished responses to the contractile agonist acetylcholine. It is possible that alteration in myocyte Ca2+ mobilization induced by these substances may influence clinical states of altered airway tone, such as asthma.

We hypothesized that endotoxin (LPS) would impair vasoconstrictor-agonist-induced calcium (Ca2+) mobilization by a nitric oxide (NO)-dependent mechanism. We incubated bovine aortic myocytes (passages 16 to 23) for 22 to 24 hours with 0 to 1.0 mg/ml Escherichia coli lipopolysaccharide (LPS). Medium (Dulbecco's modified Eagle's medium (DMEM) + 10% fetal bovine serum (FBS)) was assayed for nitrite (chemiluminescence), and myocytes were loaded with fura-2 acetoxymethyl ester (fura-2AM), after which we assessed basal and thrombin (10 U/ml)-induced peak Ca2+ mobilization by microspectrofluorimetry. LPS (0.01 to 1.0 mg/ml) led to dose-dependent nitrite accumulation, which was blocked by coincubation with N(omega)-nitro-L-arginine methyl ester (L-NAME, 1 mmol/L). LPS also impaired Ca2+ responses in a dose-dependent manner (from -13% at 0.1 mg/ml to -47% at 1.0 mg/ml, n = 8 to 43/dose). However, coincubation with L-NAME did not ameliorate the Ca2+ mobilization defect (peak Ca2+ increments: control = 419 +/-30 nmol/L, vs LPS (1 mg/ml) = 206+/-18 nmol/L (mean+/-SE), n = 15; p < 0.001; control/L-NAME: 417+/-31 nmol/L vs LPS/L-NAME: 212+/-19 nmol/L; n = 17 p < 0.001), despite inhibition of associated nitrite accumulation in the medium (control vs LPS: p < 0.001; control/L-NAME vs LPS/L-NAME: p > 0.05; LPS vs LPS/L-NAME: p < 0.001). Supplemental L-arginine augmented LPS-induced nitrite generation without affecting Ca2+ mobilization. Indomethacin failed to prevent the LPS-induced decrement in thrombin response, but did inhibit LPS-induced myocyte nitrite production, suggesting "crosstalk" between the NO-synthase and cyclo-oxygenase (COX) systems. These experiments suggest that LPS-induced vascular contractile impairment is at least partly mediated by an NO-independent impairment of agonist-induced myocyte Ca2+ mobilization. This further suggests that any important contribution of NO synthesis to LPS-induced contractile dysfunction must depend on impairment of the Ca2+ sensitivity of the contractile apparatus (i.e., pharmacomechanical coupling).

The vascular pathophysiology of preeclampsia, a hypertensive disorder unique to human pregnancy, has been postulated to be due to endothelial dysfunction, primarily manifest as deficient nitric oxide (NO) synthesis. We evaluated contraction (KCl and arginine vasopressin [AVP]) and dilation (acetylcholine and bradykinin) in small resistance-size omental arteries obtained during surgery from women with preeclampsia, postulating that these vessels would exhibit augmented contraction and diminished endothelium-dependent relaxation, most likely due to decreased NO synthesis. For comparison, vessels were also obtained from normotensive gravidas, pregnant women with chronic hypertension, or with chronic hypertension and superimposed preeclampsia, as well as from premenopausal nonpregnant controls. Vessels of approximately 200 micron in internal diameter were studied in vitro using a Mulvany-Halpern myograph. Maximal contraction due to either KCl or AVP was significantly augmented in vessels from women with preeclampsia; these vessels all exhibited endothelium- and cyclooxygenase-dependent phasic oscillations while vessels from all other groups exhibited only tonic contractions. Acetylcholine and bradykinin both led to dose- and endothelium-dependent relaxation which was unaffected by inhibitors of NO synthesis. Responses to bradykinin were similar in vessels from normal pregnant and preeclamptic women while those to acetylcholine were absent in vessels from women with preeclampsia. These data suggest specific defects in resistance-artery endothelium from women with preeclampsia.

We hypothesized that endotoxin would impair agonist-induced calcium (Ca2+) mobilization in rat mesangial cells, owing to the induction of nitric oxide synthase (NOS) and augmented nitric oxide (NO) synthesis. We measured basal and bradykinin-induced peak free cytosolic Ca2+ concentrations through microspectrofluorimetry with fura-2 in confluent mesangial cells, and assayed conditioned medium for nitrite accumulation. Prior to measurement, cells were incubated overnight in serum-supplemented medium, with or without endotoxin, 1-arginine, indomethacin, meclofenamate, or N omega-nitro-L-arginine methyl ester (L-NAME). Endotoxin (1 mg/ml) decreased bradykinin-induced peak Ca2+ responses by 35 to 60% (p < 0.0001) and increased nitrite accumulation > 6-fold (p < 0.01). Arginine supplementation further (> 9-fold, p < 0.0001) increased nitrite accumulation without changing the effect on Ca2+. Inhibition of NOS abolished increments in nitrite concentration but had no effect on impaired Ca2+ responses. Cyclooxygenase (COX) inhibitors, present during incubation with endotoxin, but not afterward, normalized bradykinin-stimulated calcium responses. Thrombin-stimulated Ca2+ responses were similarly affected. We conclude that neither NO nor prostaglandins act directly to impair agonist-induced Ca2+ mobilization following endotoxin exposure; however, this effect may be an indirect effect of COX products, including reactive oxygen intermediates.

Objective: Our purpose was to test the hypothesis that augmented basal and vasodilator agonist-stimulated synthesis of endothelium-derived nitric oxide would blunt vasoconstrictor-induced contraction and enhance relaxation in isolated femoral resistance vessels from pregnant rats., Study Design: Potassium chloride-, phenylephrine-, and angiotensin II-induced contraction and acetylcholine-induced relaxation were assessed in small (approximately 240 microns diameter) femoral resistance arteries from gravid and virgin animals studied under isometric conditions; the effects of potassium chloride, phenylephrine, and acetylcholine were also studied in the presence of nitroarginine., Results: Maximal vasoconstriction was similar in vessels from virgin and pregnant rats, whereas phenylephrine potency was slightly enhanced in vessels from gravid animals. Nitroarginine augmented contraction in both groups but with greater effect on phenylephrine potency and on submaximal potassium chloride contractions in virgins. Acetylcholine-induced relaxation did not differ between groups and was similarly, but only partially, inhibited by nitroarginine., Conclusions: Pregnancy does not result in vasoconstrictor resistance, increased basal nitric oxide synthesis, or augmented agonist-stimulated endothelium-dependent relaxation in this particular isolated rat microvascular preparation. Further, endothelium-dependent relaxation of these vessels depends only partly on nitric oxide.

We assessed mechanisms of acetylcholine- and bradykinin-induced relaxations in human omental resistance vessels. Ring segments (approximately 200 microns normalized ID) were dissected from omental biopsies obtained from women at laparotomy (nonpregnant) or at cesarean delivery (pregnant) and were studied under isometric conditions in a Mulvany-Halpern myograph. All arginine vasopressin-preconstricted vessels relaxed in a strictly endothelium-dependent manner to acetylcholine and bradykinin; maximal relaxations were not decreased by either NG-nitro-L-arginine or indomethacin. By contrast, bradykinin failed to relax vessels that had been preconstricted with potassium gluconate. In the combined presence of NG-nitro-L-arginine and indomethacin, addition of charybdotoxin, a selective antagonist of some calcium-sensitive potassium channels, did not inhibit maximal bradykinin-induced relaxation. By contrast, addition of 10 mmol/L tetraethylammonium chloride abolished relaxation in vessels from nonpregnant women but not in vessels from gravidas. We conclude that bradykinin relaxes these human resistance arteries in an endothelium-dependent but predominantly nitric oxide- and prostanoid-independent manner; relaxation likely depends on the action of an endothelium-derived hyperpolarizing vasodilator. Furthermore, in striking contrast to mechanistic insights from animal studies, human pregnancy appears to augment a mechanism of endothelium-dependent relaxation in these vessels that is insensitive to the inhibitors noted above. Whether a similar novel vasodilator mechanism in vivo contributes to the physiological vasodilation that characterizes human gestation or whether failure of such a mechanism might lead to preeclampsia remains the subject of future study.

We administered a comprehensive neuropsychological test battery, including measures of intelligence, immediate and delayed memory, attention and mental processing speed, language abilities, complex problem solving, motor skills, and depression, to 16 well-dialyzed (Kt/Vurea = 1.46 +/- 0.24) patients with end-stage renal disease (ESRD) and 12 age- and education-matched medical controls. We observed no clear neuropsychological deficits in these ESRD patients who had low average intelligence and limited educational achievement, and hypothesize that previously observed apparent deficits resulted either from very low dialysis delivery or comparison with poorly-matched historical controls. There were significant deficits in language ability and intelligence in ESRD patients with higher than median scores on the Beck Depression Inventory compared with less-depressed ESRD patients. However, this effect of depression did not result in differences between dialysis and non-ESRD patient groups.

We assessed KCl- and phenylephrine (PE)-induced vasoconstriction as well as acetylcholine (ACh)-induced endothelium-dependent vasodilation in small, isometrically mounted mesenteric arteries from virgin and gravid rats, studied in the absence and presence of NG-nitro-L-arginine (L-NNA). Neither maximal vasoconstriction nor PE potency differed significantly between vessels from virgin and pregnant rats, either in the absence or presence of L-NNA. L-NNA resulted in similar twofold leftward shifts in the PE dose-response curves for both groups. ACh-induced relaxation was potentiated in vessels from gravid rats (half-maximum effective concentration = 0.25 vs. 0.04 microM, virgin and gravid rats, respectively). After L-NNA, maximal relaxation was inhibited significantly more in vessels from gravid rats (62 vs. 31%). Likewise, maximal slope of ACh dose-response curves and ACh potency were decreased in this group so that values no longer differed from those in virgins. We conclude that pregnancy does not alter basal nitric oxide (NO) synthesis in these isolated microvessels, but it does enhance ACh-induced NO release, while apparently inhibiting the action of a NO-independent, endothelium-derived vasodilator.

Endotoxin administration decreases intrinsic responsiveness of arteries to contractile agonists, both in vivo and in vitro. Endotoxin also impairs systemic and intestinal ability to increase microvascular O2 extraction in response to decreases in O2 delivery. During endotoxemia, contractile responsiveness can be increased by stereospecific inhibitors of nitric oxide (NO) synthase, suggesting that the hypotension and loss of microvascular function caused by endotoxin may result from increased nitric oxide biosynthesis. This study tested whether inhibition of NO synthesis could reverse the systemic and intestinal oxygen extraction defects seen after endotoxin challenge in the dog. Oxygen extraction and hemodynamic responses to progressive decreases in O2 delivery (stagnant hypoxia) were measured systemically and in isolated autoperfused intestine segments in anesthetized dogs. Systemic and intestinal O2 extractions at the onset of O2 supply dependency were significantly impaired in endotoxin-challenged (n = 6) compared with control (n = 7) animals. Inhibition of NO synthase activity with N omega-nitro-L-arginine methyl ester (L-NAME), 50 mg/kg + 100 mg/kg/h, completely inhibited endothelium-dependent vasodilation responses evaluated in vitro, and significantly but incompletely reversed the systemic hypotension in animals previously given endotoxin (n = 9). Despite this improvement, critical O2 extraction ratios remained significantly reduced. Administration of L-NAME in the absence of endotoxin (n = 8) significantly increased systemic vascular resistance and decreased cardiac output and O2 delivery, but it did not impair critical O2 extraction ratios in whole body or isolated intestine. We conclude that inhibition of NO synthesis in this model of endotoxemia can improve arterial pressure without improving those microvascular functions that may influence tissue O2 extraction efficacy.