Operational aspects of terminating the doxazosin arm of The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized, practice-based trial sponsored by the National Heart, Lung, and Blood Institute (NHLBI). The double-blind, active-controlled component of ALLHAT was designed to determine whether the rate of the primary outcome-a composite of fatal coronary heart disease and nonfatal myocardial infarction-differs between diuretic (chlorthalidone) treatment and each of three other classes of antihypertensive drugs: a calcium antagonist (amlodipine), an angiotensin-converting enzyme inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin) in high-risk hypertensive persons ages 55 years and older. In addition, 10,377 ALLHAT participants with mild to moderate hypercholesterolemia were also enrolled in a randomized, open-label trial designed to determine whether lowering serum LDL cholesterol with an HMG CoA reductase inhibitor (pravastatin) will reduce all-cause mortality as compared to a control group receiving "usual care." In January 2000, an independent data review committee recommended discontinuing the doxazosin treatment arm. The NHLBI director promptly accepted the recommendation. This article discusses the steps involved in the orderly closeout of one arm of ALLHAT and the dissemination of trial results. These steps included provisional preparations; the actual decision process; establishing a timetable; forming a transition committee; preparing materials and instructions; informing 65 trial officers and coordinators, 628 active clinics and satellite locations, 313 institutional review boards, over 42,000 patients, and the general public; reporting detailed trial results; and monitoring the closeout process. Control Clin Trials 2001;22:29-41

Reduction of stroke incidence after myocardial infarction with pravastatin: the Cholesterol and Recurrent Events (CARE) study. The Care Investigators.

BACKGROUND: The role of lipid modification in stroke prevention is controversial, although increasing evidence suggests that HMG-CoA reductase inhibition may reduce cerebrovascular events in patients with prevalent coronary artery disease. METHODS AND RESULTS: To test the hypothesis that cholesterol reduction with pravastatin may reduce stroke incidence after myocardial infarction, we followed 4159 subjects with average total and LDL serum cholesterol levels (mean, 209 and 139 mg/dL, respectively) who had sustained an infarction an average of 10 months before study entry and who were randomized to pravastatin 40 mg/d or placebo in the Cholesterol and Recurrent Events (CARE) trial. Using prospectively defined criteria, we assessed the incidence of stroke, a prespecified secondary end point, and transient ischemic attack (TIA) over a median 5-year follow-up period. Patients were well matched for stroke risk factors and the use of antiplatelet agents (85% of subjects in each group). Compared with placebo, pravastatin lowered total serum cholesterol by 20%, LDL cholesterol by 32%, and triglycerides by 14% and raised HDL cholesterol by 5% over the course of the trial. A total of 128 strokes (52 on pravastatin, 76 on placebo) and 216 strokes or TIAs (92 on pravastatin, 124 on placebo) were observed, representing a 32% reduction (95% CI, 4% to 52%, P=0.03) in all-cause stroke and 27% reduction in stroke or TIA (95% CI, 4% to 44%, P=0.02). All categories of strokes were reduced, and treatment effect was similar when adjusted for age, sex, history of hypertension, cigarette smoking, diabetes, left ventricular ejection fraction, and baseline total, HDL, and LDL cholesterol and triglyceride levels. There was no increase in hemorrhagic stroke in patients on pravastatin compared with placebo (2 versus 6, respectively). CONCLUSIONS: Pravastatin significantly reduced stroke and stroke or TIA incidence after myocardial infarction in patients with average serum cholesterol levels despite the high concurrent use of antiplatelet therapy.

Entry into, and resuscitation from, the viable but nonculturable state by Vibrio vulnificus in an estuarine environment.

Using plate counts, total cell counts, and direct viable counts, we examined the fate of cells of Vibrio vulnificus placed into natural estuarine waters during both winter and summer months. Cells inoculated into membrane diffusion chambers and placed into estuarine waters entered into a viable but nonculturable (VBNC) state in January and February, when the water temperatures were low (average, < 15 degrees C). In contrast, when cells in the VBNC state were placed into the same waters in the warmer months of August through November (average water temperature of ca. 21 degrees C), the cells appeared to undergo a rapid (typically, within 24 h) resuscitation to the fully culturable state. These results were independent of whether the cells were in the logarithmic or stationary phase and whether they were encapsulated or not. This study indicates that the inability to isolate V. vulnificus from cold estuarine sites may be accounted for by entrance of the cells into a VBNC state and that recovery from this state in natural environments may result from a temperature upshift.

Effect of osmotic variation on the outer membrane proteins of Vibrio vulnificus: identification of a major heat-modifiable protein.

Cells of the moderately halophilic bacterium Vibrio vulnificus showed marked morphological changes, manifested primarily by pronounced cell elongation when grown in a defined medium with increased salt concentrations of 0.5 to 2.0%. These morphological changes were not accompanied by changes in outer membrane proteins (Omp). A similar lack of Omp variation was observed when cells were grown in heart infusion broth containing 1-2% NaCl. Osmotic upshock during growth also had no effect on Omp profiles. A heat modifiable protein with a molecular weight of 38 kD similar to Omp A of Escherichia coli, was identified in cells grown in heart infusion broth. The results suggest that under these osmotic conditions V. vulnificus may not need to regulate transport through modification of its outer membrane proteins.

Regulation of proteolytic activity of Vibrio vulnificus by iron-containing compounds.

Previous studies have shown that the Vibrio vulnificus is able to use hemoglobin and the hemoglobin-haptoglobin complex to reverse iron limitation. In addition, we report here that free hemin, as well as hemin bound to albumin, will reverse iron-limited growth. While protease negative mutants were able to use hemin and hemoglobin, they were unable to compete as successfully for albumin-bound hemin. Using Luria broth with the iron chelator ethylenediamine-di(o-hydroxyphenylacetic acid) (EDDA), no changes in proteolytic activity were seen. In contrast, growth in a low iron defined medium resulted in a loss of proteolytic activity. This loss was reversed by the addition of hemin or hemoglobin but not by inorganic iron or globin alone. Since one portal of entry of this organism is pre-existing wounds, hemoglobin released during cell damage may be important in activating extracellular proteases leading to the massive cell damage seen with this vibrio.

Reversal of hypotension induced by Vibrio vulnificus lipopolysaccharide in the rat by inhibition of nitric oxide synthase.

Intravenous infusion of Vibrio vulnificus lipopolysaccharide (LPS) (1 mg/kg body wt) in rats caused a dramatic drop in mean arterial pressure within 10 min and a further decline in mean arterial pressure and heart rate which lead to death between 25 and 70 min. Rats treated with LPS followed 10 min later by the intravenous infusion of NG-monomethyl-L-arginine (L-NMMA, 20 mg/kg body wt) showed an initial drop in mean arterial pressure owing to the LPS infusion, followed by a transient rise in mean arterial pressure which lasted for approximately 40 min after the infusion of L-NMMA. The pressure values then remained level for at least 150 min post-LPS infusion. Control rats treated with equivalent volumes of saline infusion showed stable values of mean arterial pressure and heart rate. Additional control rats receiving L-NMMA alone showed the transient rise in mean arterial pressure, followed by a return to the baseline values. The results indicate that the symptoms of endotoxic shock resulting from V. vulnificus LPS may result in part from the stimulation of the activity of nitric oxide synthase. Inhibition of nitric oxide synthase by L-NMMA is a possible treatment for toxic shock induced by V. vulnificus.

Use of colistin-polymyxin B-cellobiose agar for isolation of Vibrio vulnificus from the environment.

Colistin-polymyxin B-cellobiose agar was employed for the isolation of Vibrio vulnificus from shellfish. Isolates were examined phenotypically and with a gene probe and monoclonal antibody specific for V. vulnificus. Results indicated that colistin-polymyxin B-cellobiose agar is superior to both sodium dodecyl sulfate-polymyxin B-sucrose agar and thiosulfate-citrate-bile salts-sucrose agar in its ability to select and differentiate this species from background vibrios.

Physiological effects of the lipopolysaccharide of Vibrio vulnificus on mice and rats.

Vibrio vulnificus is a pathogenic, marine, Gram-negative bacterium which commonly enters and infects humans via open wounds or the ingestion of raw seafood. The lipopolysaccharide (LPS) of V. vulnificus has recently been characterized, but the biological activity of this putative endotoxin is unknown. Three treatment groups were used to test its activity: saline (negative control), the LPS of Salmonella typhimurium (a known endotoxin), and the LPS of V. vulnificus. Whereas, intravenous injections of the S. typhimurium LPS caused mortality in two strains of mice, V. vulnificus LPS was not lethal. However, intraperitoneal injections into rats of both V. vulnificus and S. typhimurium LPS were pyrogenic. Intravenous injections of V. vulnificus LPS in rats caused decreased mean arterial pressure within 10 min which further declined, leading to death in 30 to 60 min. S. typhimurium LPS caused similar responses at the same concentration. The data suggest that the LPS of V. vulnificus may be a factor contributing to the virulence of this organism.

Phenotypic evaluation of acapsular transposon mutants of Vibrio vulnificus.

Translucent, avirulent spontaneous phase variants of Vibrio vulnificus MO6-24 reverted back to the original opaque, encapsulated phenotype under both in vivo and in vitro conditions. Two translucent, acapsular mutants, which did not show phase variation, were constructed by using the transposon Tn5 IS50L::phoA (TnphoA). Loss of capsule was accompanied by decreases in virulence, hydrophilicity, and serum resistance. The ability to utilize transferrin-bound iron for growth was lost in only one of the two unencapsulated mutants. Our data emphasize the apparent importance of capsule in the virulence of V. vulnificus and indicate that utilization of transferrin-bound iron is independent of encapsulation.

Ability of Vibrio vulnificus to obtain iron from hemoglobin-haptoglobin complexes.

It has been suggested that the normal serum protein, haptoglobin (Hp), serves a bacteriostatic role by binding free hemoglobin (Hm), thus making heme iron unavailable for bacterial growth. Previous studies showed that, unlike Escherichia coli, Vibrio vulnificus was able to overcome this Hp-blocking effect. We report here a study on the iron-withholding property of the three major human Hp phenotypes, Hp 1, 2, and 2-1. Results of experiments with human serum showed that V. vulnificus C7184 was able to obtain iron from Hm bound to Hp types 1 and 2, but not that bound to Hp 2-1. E. coli 2395-80, on the other hand, was unable to overcome the blocking effect of any Hp phenotype. Using purified Hp 1, we also demonstrated that, although V. vulnificus was unable to grow in a deferrated medium without an additional iron source, it was able to grow with the addition of the Hm-Hp complex.

Identification of environmental Vibrio vulnificus isolates with a DNA probe for the cytotoxin-hemolysin gene.

We screened 44 lactose-positive Vibrio strains isolated from the marine environment for homology with a 3.2-kilobase DNA fragment encoding the Vibrio vulnificus cytotoxin-hemolysin gene. All 29 marine isolates identified as V. vulnificus on the basis of numerical taxonomy and DNA-DNA hybridization studies hybridized with the cytotoxin gene probe, as did all V. vulnificus reference strains. Homologous gene sequences were identified in no other lactose-positive marine vibrio isolates nor in 10 other Vibrio species.

Correlation between virulence and colony morphology in Vibrio vulnificus.

Of 38 isolates of Vibrio vulnificus examined, all avirulent strains produced only translucent colonies. All virulent strains, with the exception of biogroup 2 (eel pathogens), exhibited both opaque and translucent colonies. Isogenic morphotypes were examined for a variety of phenotypic and virulence traits. Only the ability to utilize transferrin-bound iron and the presence of a surface polysaccharide were found to correlate with colony opacity and virulence.

Bioluminescence in a strain of the human pathogenic bacterium Vibrio vulnificus.

We report the existence of a bioluminescent strain of the human pathogen Vibrio vulnificus. The isolate was obtained from blood following a fatal wound infection and thus represents the first description of an infection caused by a luminescent bacterium.

Siderophore production by Vibrio vulnificus.

Previous studies in our laboratory, as well as clinical evidence, have suggested that increased iron levels in the host may be important in infections caused by the halophilic pathogen Vibrio vulnificus. To study iron acquisition, we induced siderophore production by growth in a low-iron medium, and biochemical testing indicated the production of both hydroxamate- and phenolate-type siderophores. The siderophores were extracted from growth filtrates with ethyl acetate (for phenolates) and phenol-chloroform-ether (for hydroxamates). These extracts enhanced the growth of V. vulnificus when the bacterium was grown in iron-limited medium. The ability of these siderophores to stimulate the growth of Salmonella typhimurium LT-2 enb-7 (a mutant deficient in the biosynthesis of enterochelin) and Arthrobacter flavescens JG-9 (a hydroxamate auxotroph) supported the conclusion that V. vulnificus produces both hydroxamate- and phenolate-type siderophores.

Role of iron in the pathogenesis of Vibrio vulnificus infections.

Infections with Vibrio vulnificus resulting in septicemia and high mortality have been correlated with pre-existing liver disease and hemochromatosis. As these conditions are associated with impaired iron metabolism and as iron availability in the host has been implicated in the pathogenicity of a number of bacterial infections, the role of iron as a possible factor in the pathogenesis of V. vulnificus was examined. Injection of mice with iron resulted in a lowering of the 50% lethal dose from 10(6) to 1.1 cells and in a reduction in the time of death postinfection. Elevated serum iron levels were also produced by damaging livers with injections of CCl4. The inoculum size required to kill these mice was directly correlated with serum iron levels. Since the portal of infection of this organism may be ingestion of contaminated seafood, the effects of iron upon orally induced infection were also studied. The effects of adding iron, transferrin, or Desferal (an iron chelate) upon the growth of V. vulnificus in human and rabbit sera were also examined. Iron appeared to be the limiting factor in the ability of this organism to survive or grow in mammalian sera. These results, both in vitro and in vivo, provided strong evidence that iron may play a major role in the pathogenesis of V. vulnificus.