Clinical and economic outcomes in patients switched to simvastatin in a community-based family medicine practice.

BACKGROUND: The introduction of a generic formulation of simvastatin has created the potential to provide significant low-density lipoprotein cholesterol (LDL-C) reduction in a highly cost-effective manner. METHODS: This retrospective cohort analysis utilised electronic medical record data from a United States, community-based, independent physician family medicine practice. Patients switched from other statins or statin combinations to simvastatin by the family medicine physicians during routine patient care from January 2002 to October 2008 were identified. Equivalent statin dosing, lipid panel changes and National Cholesterol Education Program--Adult Treatment Panel III (NCEP) LDL-C goal attainment rates were compared preswitch and postswitch. The potential economic impact of simvastatin switching was also evaluated. RESULTS: A total of 78 patients were identified, and in 76.9% of the switches, an equipotent dose of simvastatin was prescribed. All lipid fractions showed small, non-significant increases, with LDL-C having a 2.2 mg/dl (0.06 mmol/l) increase after switching (p = 0.476). NCEP LDL-C goal attainment rates were 79.5% and 78.2% before and after switching, respectively (p = 1.00). Modelled annual cost savings associated with switching were estimated at $671.99 per patient. CONCLUSIONS: These results demonstrate that an independent family medicine physician practice can successfully perform statin therapeutic substitution during routine patient care. Equivalent clinical outcomes with regards to changes in lipid fractions and NCEP LDL-C goal attainment were observed in conjunction with the potential for reduced costs for patients.

An elusive role for glycosylation in the structure and function of reproductive hormones.

The crescendo of events leading first to ovulation and subsequently to birth is orchestrated by a broad repertoire of hormones. The major hormones of the ovulatory cycle are representatives of four hormone classes: neurotransmitters, releasing factors, trophic hormones acting on target tissues, and steroid-like molecules released by the target tissues. The punctuate and staccato rhythm of the neurotransmitters and releasing hormones relentlessly drive the swelling and protracted wave of activity by the luteotrophic and steroid hormones. Carbohydrates alone are notably absent as hormones and the predominant role for glycosylation appears to be the conferment of increased solubility to endocrine molecules, either during their manufacture or by modulating circulatory half-life. Rarely considered examples of the importance of glycosylation in reproductive hormones include adenosine, important for spermatozoan activity, and the hormone-binding globulins, which ensure the aqueous transport of hydrophobic steroids. The archetype glycoprotein hormones, especially human chorionic gonadotrophin (HCG), are discussed more extensively, as the structural and functional roles of carbohydrate in these hormones have been studied exhaustively. Conversely, the direct involvement of HCG and the importance of its carbohydrate for autonomous growth, in both placental invasion and tumorigenesis, has received little attention in the literature.

Photoionization of gas-phase versus ion-beam-desorbed dopamine with femtosecond laser pulses.

We have investigated the photoionization of gas-phase and ion-beam desorbed dopamine using femtosecond laser pulses at wavelengths of 800, 400, 267, and 200 nm. Photoionization of gas-phase dopamine is found to produce the molecular ion, and three fragment ions at all four wavelengths, with the branching ratios strongly wavelength dependent. Photoionization at 400 and 267 nm yields the highest molecular ion signal, while that at 800 and 200 nm produces very little molecular ion signal. An excited-state lifetime of approximately 10 ps following 267-nm excitation has been measured for dopamine using time-resolved pump-probe techniques. The short-lived excited state suggests that internal conversion, intersystem crossing, and/or dissociation is a concern when ionizing at this wavelength using longer laser pulses. Photoionization of ion-beam-desorbed dopamine exhibits a large degree of fragmentation at all four wavelengths, though 267-nm photoionization produces the highest yield of dopamine fragment ions. Power dependence studies show a high degree of internal excitation. A direct comparison of ion yields obtained for photoionization of ion-beam-desorbed dopamine at 267 nm to that for SIMS shows a 20-fold increase in signal.

Vacuum ultraviolet single photon versus femtosecond multiphoton ionization of sputtered germanium clusters.

Neutral atoms and clusters desorbed from a solid germanium surface by ion bombardment are detected by laser postionization and time-of-flight mass spectrometry. Two different photoionization schemes are compared which are generally believed to be candidates for the 'soft' ionization of polyatomic species without significant photon induced fragmentation. First, a single photon ionization process is employed using an F2 laser as an intense VUV source with a photon energy in excess of all relevant ionization potentials. It is shown that the available laser pulse energy is sufficient to saturate the ionization of Ge atoms and all detected Ge(n) clusters. The resulting mass spectra are compared to those obtained with a non-resonant multiphoton ionization process using a high intensity laser delivering pulses of 250 femtoseconds duration at a wavelength of 267 nm. Also in this case, the ionization process can apparently be driven into saturation. The mass spectra measured under these conditions are found to be almost identical to those obtained using single photon ionization. We take this as an indication that the results obtained with both postionization techniques closely reflect the true cluster sputtering yields and, in particular, are not dominated by photon induced fragmentation.

Performance characteristics of a chemical imaging time-of-flight mass spectrometer.

A chemical imaging time-of-flight secondary ion mass spectrometer is described. It consists of a liquid metal ion gun, medium energy resolution reflectron mass analyzer, liquid nitrogen cooled sample stage, preparation chamber and dual stage entry port. Unique features include compatibility with laser postionization experiments, large field of view, cryogenic sample handling capability and high incident ion beam current. Instrument performance is illustrated by the characterization of scanning electron microscopy grids, silver and functionalized polystyrene beads and the postionization of an organic overlayer on a gold substrate.

Postionization of molecules desorbed from surfaces by keV Ion bombardment with femtosecond laser pulses.

We report the use of femtosecond laser photoionization of sputtered neutral molecules to enhance the sensitivity of detection and to improve the prospects for molecule-specific imaging experiments. Results are presented for patterned metal oxides, polycyclic aromatic hydrocarbons and several amino acids. In addition to increased signal levels, we find that is photoionization generally yields simpler mass spectra than the corresponding SIMS spectra, although considerable fragmentation is observed in both cases.

Does insulin therapy have a hypertensive effect in type 2 diabetes?

In this prospective study, the 24-h blood-pressure profile of 12 patients with type 2 diabetes was monitored before, at 6, and at 12 weeks after initiation of insulin therapy, to determine whether commencement of insulin therapy increases blood pressure in these patients. Insulin dosage adjustment was carried out by using a predetermined algorithm according to body weight and degree of hyperglycemia. The mean insulin dosage at 12 weeks was 72.9 +/- 3.9 units/day. This was associated with an increase in systolic blood pressure from 134.6 +/- 4.3 mm Hg to 144.8 +/- 4.5 mm Hg (p = 0.0001), diastolic blood pressure from 71.9 +/- 2.6 mm Hg to 74.9 +/- 2.2 mm Hg (p = 0.0001), and body mass index (BMI) from 27.2 +/- 0.8 kg/m2 to 29.6 +/- 0.8 kg/m2 (p = 0.0001). Multiple regression analysis showed insulin dosage to be a significant independent factor (p = 0.0003) accounting for 63% of the variance in blood pressure change after adjusting for age, diastolic blood pressure, and base HbA1c. We conclude that insulin therapy may have a deleterious effect on blood pressure in patients with type 2 diabetes. However, in the clinical setting, it is difficult to isolate this from the confounding effect of weight gain.

Indapamide is as effective as captopril in the control of microalbuminuria in diabetes.

Microalbuminuria is a predictor of overt diabetic nephropathy and macrovascular disease. Thirty-one diabetic patients with persistent urinary albumin excretion rate (AER) of 20-200 mu g min-1 were randomised to receive indapamide 2.5 mg or captopril 37.5 mg daily for 12 weeks. After a 4-week washout, patients received the alternate agent for 12 weeks. Resting blood pressure (BP), AER, cholesterol, triglycerides, and HbA1c were measured at baseline, after 6 and 12 weeks of each treatment, and after a 4-week washout period following each treatment arm. Results from patients who completed at least one treatment arm were analysed by repeated-measures analysis of variance (ANOVA). AER (median value and interquartile range) decreased significantly from baseline after treatment with indapamide and captopril [60(27-106) vs. 40(14-112) and 33(17-100); p < 0.005], but there was no difference between the effects of the two agents. Mean systolic BP (SBP) was also significantly reduced with treatment, and no difference was noted between the effects of the two agents. No correlation between changes in AER and SBP was noted with either agent. Diastolic blood pressure (DBP), cholesterol, triglycerides, and HbA1c did not change during the study. These results suggest that indapamide is an effective alternative to angiotensin-converting enzyme (ACE) inhibitors in the treatment of diabetic patients with microalbuminuria.

The antibodies causing thyroid stimulating hormone-binding inhibition (TSH-BI) are not responsible for the specific inhibition of gonadal steroidogenesis by Graves' sera.

Graves' disease is attributed to the presence of autoantibodies with agonist activity which interact with the TSH receptor causing thyroid hyperstimulation and hyperthyroidism. The degree of TSH-binding inhibition (TSH-BI) caused by a Graves' serum in a TSH radioligand receptor assay is considered to be an index of the prevalence of anti-TSH receptor autoantibodies in that serum. We have previously shown that the specific inhibition by Graves' serum of hCG-stimulated steroidogenesis by Leydig cells was at a site distal to receptor binding and second messenger activation. In this report, we have investigated whether the effect of Graves' serum upon Leydig cells is a property of the constitutive antibodies. Immunoglobulin-enriched fractions were obtained from Graves' and normal sera using three increasingly rigorous procedures; ammonium sulphate precipitation, caprylic acid treatment and Protein A or G-affinity purification. The TSH-BI was determined for untreated and extracted sera in two radioreceptor assays developed for use with serum, one using human thyroid membranes and the other using HeLa cells transfected with the human TSH receptor, and the results were compared with effects in the Leydig cell steroidogenesis bioassay. The specific inhibition of hCG-stimulated Leydig cell steroidogenesis by Graves' sera was not retained in the antibody fraction causing TSH-BI. Thus, the inhibitory factor appears not to be an antibody and we are now attempting to purify and identify the responsible factor from Graves' serum.

Comparative effects of indapamide and captopril on blood pressure and albumin excretion rate in diabetic microalbuminuria.

Nephropathy affects about one third of diabetic patients and its onset can be predicted almost a decade in advance by detecting small quantities of albumin in the urine (microalbuminuria). Thus, detection of proteinuria or microalbuminuria in diabetic patients carries important implications and merits intervention. Strategies for delaying the relentless progression of microalbuminuria to diabetic nephropathy and ultimately end-stage renal failure are focused on improving glycemic control and reducing blood pressure. Studies with beta-blockers, calcium antagonists, diuretics, and angiotensin-converting enzyme (ACE) inhibitors in hypertensive diabetics with microalbuminuria have shown a significant reduction in urinary albumin excretion rates (AER), with effective lowering of blood pressure. In a crossover study, we compared the effects of captopril versus indapamide as monotherapy for 12 weeks on AER and blood pressure in 31 diabetic patients with established microalbuminuria. The 2 drugs were equally effective in reducing AER (average reduction 30-40%) and had comparable antihypertensive effects.

Epitope mapping of the human TSH receptor; structure function studies.

With the aid of recombinant DNA technology (PCR/site directed mutagenesis, sequencing) the full length coding region of the human TSH receptor was manipulated to place a specific epitope peptide tag (FLAG epitope sequence) at the carboxyl end of the protein. The resulting construct was cloned into a eukaryotic expression vector and stably transfected into HeLa cells. The expression/translation of the tagged TSH receptor molecule was monitored by immune-precipitation and western blotting of protein lysates, and was found to be expressed at considerable levels using the commercially available antibodies directed towards the FLAG epitope. This analysis revealed two discrete specific bands 90-120 KDa representing, presumably, differently glycosylated forms of the receptor. TSH radio receptor assays demonstrated that the FLAG tagged TSH receptor bound TSH comparable with the wild type receptor. Furthermore TSH stimulated cAMP response in these transfected cells were comparable to the wild type receptor, thus demonstrating that the tagged receptor was functionally identical to the transfected wild type receptor. These cell lines will be of great value when analysing TSH/receptor or receptor/autoantibody interactions considering the availability of well characterized experimental anti-TSH receptor sera.

Epitope mapping of a recombinant human TSH receptor extracellular domain: identification of a predominant epitope using animal sera.

The extracellular domain of the TSH receptor (TSHR-561, amino acids #78-389) was expressed as a hexa-histidine fusion protein in bacteria. The recombinant protein was purified to homogeneity and used to immunize porcine and ovine species. High titre antibodies were obtained from both species that recognized the recombinant protein in Western blot analysis but failed to interfere with the TSH radio receptor assay. An epitope library was constructed and screened with affinity purified ovine and porcine antisera and detected a number of positive clones. Sequence analysis revealed that all of the epitopes contained sequences derived from the carboxyl terminus of the recombinant immunogen. One clone defined an epitope covering 16 amino acids from the carboxyl terminus and was the common epitope found in all of the other clones. Western blot screening of a large panel of Graves' sera with recombinant TSH receptor protein identified one patient sera that also recognized linear epitopes in the TSHR-561 protein. Experimentation demonstrated that the linear epitope recognized by this human sera was identical to the sequence recognised by the animal antisera. This sequence is unique to the TSH receptor and will be useful in further studies to analyze the TSH receptor protein.

Novel splicing variants of the human thyrotropin receptor encode truncated polypeptides without a membrane-spanning domain.

The thyrotropin receptor is of fundamental importance to normal thyroid function and is considered to be the predominant antigen affected by the autoantibodies of Graves' autoimmune hyperthyroidism. The identification of the epitopes on the receptor to which the autoantibodies bind or the mechanism by which the autoantibodies arise remain to be established. In this report we have analysed in detail thein vivo transcription of the human TSH receptor gene (hTSH-R), demonstrating the presence of numerous novel TSH receptor transcripts. Northern blot analysis of mRNA from human thyroid tissue using a radiolabelled cDNA probe specific for the extracellular domain of the hTSH-R revealed the presence of small polyadenylated mRNAs, in addition to the full-length hTSH-R mRNA. A PCR strategy devised to clone transcripts with 3' polyadenylation and 5' hTSH-R specific sequences was used to clone five different hTSH-R transcripts (hTSH-R. ST1 to ST5; 250bp-1.7 kb) from human thyroid tissue. Sequence analysis demonstrated that the small transcripts arose by alternative splicing of the hTSH-R mRNA. The transcripts were associated with polysomes and were demonstrated in human thyroid tissue from patients suffering from Graves' disease, sporadic goiter as well as in healthy lobes of thyroid tissue.In situ hybridization demonstrated that two of the alternative transcripts adopted a tissue distribution pattern identical to that of the full-length hTSH-R transcript. The two major truncated transcripts ST4 and ST5 contained unique sequences at the 3' end of the mRNAs and thus potentially represent the molecular origin of soluble TSH receptor variants which have been postulated on numerous occasions.

Obese patients with type 2 diabetes poorly controlled by insulin and metformin: effects of adjunctive dexfenfluramine therapy on glycaemic control.

Dexfenfluramine is well known for its weight reducing action and has been reported to improve glycaemic control in obese Type 2 diabetic patients not adequately controlled on conventional oral hypoglycaemic therapy. In this double-blind placebo-controlled study, 20 obese Type 2 diabetic patients with mean HbA1c of 8.8 +/- 0.5% (normal range 3.5-6.0%), and mean body mass index (BMI) of 34.4 +/- 1.0 kg m-2, who were poorly controlled on insulin (mean dosage 58.0 +/- 6.1 units day-1) were randomized to receive either additional dexfenfluramine or placebo for 12 weeks. Seventeen of these patients were already taking maximum tolerated metformin therapy (mean dosage 1.6 +/- 0.2 g day-1) and the other three were unable to tolerate any at all. At baseline, the dexfenfluramine and placebo groups were similar in all parameters studied. After the 12-week treatment period, median HbA1c had fallen in dexfenfluramine treated patients from 8.5 (interquartile range (IR): 7.5-10.3) to 7.1% (IR: 6.7-7.5; p < 0.02). The fall in HbA1c in individual patients after treatment with dexfenfluramine was strongly associated with weight loss (r = 0.69; p < 0.04), although as a group the changes in weight and BMI were not statistically significant. Placebo was without effect. These results show that in the obese patient with Type 2 diabetes who is poorly controlled despite large daily doses of insulin and metformin, adjunctive dexfenfluramine can improve glycaemic control without exacerbating weight gain.

Serum unmasks the binding of thyroid-stimulating hormone to endogenous and transfected receptors: evidence for a soluble form of the receptor in human thyroid.

A specific homologous radioligand receptor assay for thyroid-stimulating hormone (TSH) using bovine thyroid membranes was adapted for use with human thyroid. Specific 125I-labelled TSH binding was detected in the 3000 g membrane pellet from bovine thyroid but predominantly in the 3000 g supernatant of the human thyroid homogenate. Both assays required incubation in the presence of 10% serum, whilst the assay using human thyroid could only be precipitated using polyethylene glycol (PEG). The serum requirement transcended a possible role as carrier protein and unmasked specific TSH binding. Molecular sieving determined that the active fraction of the serum had an apparent size of 30,000-100,000. The requirement for PEG-assisted precipitation of the TSH receptor assay was a consequence of the TSH-binding entity from Graves' thyroid behaving like a soluble 'receptor': it did not sediment with the membranes, passed a 0.2 microns filter and, upon molecular sieving, had an apparent size of 300,000-1,000,000. A full-length TSH receptor cDNA was cloned from a human Graves' thyroid library and stably transfected cell lines expressing the TSH-receptor protein were constructed using human HeLa and murine 3T3 cells. Specific TSH binding was unmasked by serum in the human cell lines, as observed for the human thyroid TSH receptor, whereas serum hindered TSH binding in the murine cell lines. A soluble form of the receptor was not released from the cells and was not produced in conditions which demonstrated a soluble receptor-like binding component in human thyroid tissue.

Graves' autoimmune serum inhibits gonadal steroidogenesis: development of a Leydig cell bioassay to identify broad spectrum anti-endocrine autoantibodies.

In order to establish an assay for the detection of autoimmune sera with broad spectrum activity, we have investigated the effect of unselected normal and Graves' disease sera upon steroidogenesis by gonadal cells. Steroidogenesis was enhanced by the addition of normal serum in a 3-h primary Leydig cell bioassay, but was inhibited by the majority of Graves' sera. The inhibition was not related to clinical thyroid parameters, such as the severity of the TSH-binding inhibition index, and was not overcome by other agonists or second messenger supplements. Although pituitary TSH preparations bound to and stimulated Leydig cells, TSH receptor mRNA was not detectable and pure recombinant TSH failed to bind or stimulate, indicating contamination of pituitary TSH with LH. The binding of hCG to the Leydig cell luteinizing hormone receptor was not perturbed by the Graves' autoimmune sera, indicating that cross-reactive anti-TSH receptor antibodies were not responsible for the inhibition. By use of intermediates in the stimulatory pathway, the site of Graves' serum inhibition was identified to be distal to hormone receptor/adenylate cyclase coupled responses and proximal to supply of cholesterol for steroidogenesis.

Regression of microalbuminuria: results of a controlled study, indapamide versus captopril.

Our aim was to assess the effect of blood pressure treatment on albumin excretion rate (AER) in diabetic patients using two antihypertensive agents with different modes of action: indapamide and captopril. Patients with persistent microalbuminuria on two occasions (AER 20-200 micrograms/min) entered a randomized crossover study of 12 weeks of therapy with a constant dose of either indapamide 2.5 mg daily or captopril 12.5 mg three times daily, with a 4-week washout between therapy periods. Blood pressure was measured using a random-zero sphygmomanometer and AER by radioimmunoassay on a timed urine collection. Results (mean +/- standard deviation) were analyzed by repeated measures of analysis of variance after log transformation of AER data. Twelve patients [nine men; mean age 58 +/- 7.5 years (range 49-73 years), all with non-insulin-dependent diabetes mellitus (NIDDM)] were studied. Both blood pressure [initial mean systolic 144 +/- 14 mm Hg (range 124-166)/initial mean diastolic 85 +/- 6 mm Hg (range 75-96)] and AER [initial 92 +/- 36 micrograms/min (range 36-161)] were significantly reduced below basal levels (at the 0.05 level) at all study intervals by both antihypertensive agents. The results show the importance of blood pressure and its treatment on AER in patients with NIDDM. In this study, indapamide was as effective as an angiotensin-converting enzyme inhibitor in reducing both blood pressure and microalbuminuria.

The effects of dexfenfluramine on blood glucose control in patients with type 2 diabetes.

Dexfenfluramine has been shown to promote weight loss in overweight people. The present double-blind study was designed to test whether the addition of dexfenfluramine to conventional oral hypoglycaemic treatment would promote weight loss and improve blood glucose control in overweight patients with Type 2 diabetes. The 34 patients studied were randomly assigned to dexfenfluramine or placebo therapy which was added for 12 weeks to their existing treatment regimens of metformin with or without a sulphonylurea. Dexfenfluramine treatment was associated with a significant reduction in weight (98.7 +/- 5.0 (+/- SE) vs 94.9 +/- 5.2 kg; p less than 0.001), BMI (35.0 +/- 1.2 vs 33.6 +/- 1.9 kg m-2; p less than 0.001), HbA1c (7.5 +/- 0.3 vs 6.3 +/- 0.2%; p less than 0.001), fructosamine (313.9 +/- 17.6 vs 274.3 +/- 10.4 mumol l-1; p less than 0.01), systolic (137 +/- 5 vs 128 +/- 6 mmHg; p less than 0.05), and diastolic blood pressure (85 +/- 2 vs 73 +/- 3 mmHg; p less than 0.001). At the end of the study period, the dexfenfluramine treated group had a significantly lower HbA1c (6.3 +/- 0.2 vs 7.2 +/- 0.4; p less than 0.05), fructosamine level (274.3 +/- 10.4 vs 313.3 +/- 16.1 mumol l-1; p less than 0.05) and diastolic blood pressure (73 +/- 3 vs 81 +/- 3 mmHg; p less than 0.03) when compared with the placebo group. In those patients treated with dexfenfluramine, the reduction in HbA1c and blood pressure did not correlate with the decrease in BMI (r = 0.44 and 0.12, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Increased oxidizability of plasma lipoproteins in diabetic patients can be decreased by probucol therapy and is not due to glycation.

Atherosclerosis is considered to be the major complication of diabetes mellitus. Since diabetic patients have increased blood levels of lipid peroxidation products we investigated whether the susceptibility of blood components to oxidation is altered in this disease. We analysed the parameters characterizing the extent of oxidative change and the antioxidant status of low density lipoprotein (LDL) and high density lipoprotein (HDL) in a group of diabetic patients and in a control population. LDL oxidizability was significantly higher for patients (P = 0.001) than for individuals in the control group. There were no significant differences in the alpha-tocopherol content or levels of performed peroxides in LDL samples isolated from diabetic patients and control individuals which could account for this effect. Similarly, LDL glycation, common in diabetes mellitus, was not responsible, since LDL glycated in vitro was more rather than less resistant to oxidation. Even the presence of unbound glucose at normal or elevated physiological concentrations had a delaying effect on the oxidation of LDL. The increased oxidizability of LDL isolated from diabetic patients could be reduced to control levels by a 6-week standard treatment with Probucol, originally applied to reduce their blood cholesterol.