Search PubMed⌕ Search

Biomedical subjects

M Epstein

Publications and source records attributed to M Epstein.

At least 73 records · Page 4Linked to original sources
PubMed1997

The calcium antagonist controversy: the emerging importance of drug formulation as a determinant of risk.

Calcium antagonists are one of the widely available classes of antihypertensive agents. Their broad appeal is attributable to several features, including their efficacy, their beneficial characteristics such as metabolic neutrality, and the occurrence of relatively few nuisance-type side effects. Despite these attributes, a number of retrospective analyses have suggested that calcium antagonists may be detrimental and may both promote adverse cardiovascular events and increase the risk of cancer by interfering with cellular apoptosis. On the basis of this and other retrospective analyses, Furberg and Psaty (Am J Hypertens 1996; 9: 122-125) have proposed that the use of calcium antagonists as first-line antihypertensive agents should be discontinued. I have previously countered these allegations and have suggested that they are not relevant to the newer calcium antagonist formulations in current use. It is not widely appreciated that different formulations of the same chemical moiety can produce markedly different hemodynamic and neurohormonal effects, due to differences in the rate of drug delivery into the systemic circulation. During chronic treatment with dihydropyridine calcium antagonists, major fluctuations in blood pressure (rapid onset and offset of antihypertensive effects) during the dosing interval may occur for drugs and formulations that are short acting. In contrast, slow-release formulations of otherwise rapidly absorbed dihydropyridines achieve a more gradual and sustained antihypertensive effect. It is probable that newer calcium antagonist formulations that are truly once daily and do not provoke intermittent sympathetic activation or a cardioacceleratory response will not promote adverse cardiovascular events.

Calcium Channel Blockers↗
PubMed1997

Calcium channel blockers and hypertension: evolving perspective--1996.

In recent years, calcium channel blockers (CCBs) have been used extensively in the United States and elsewhere as antihypertensive agents, and their availability has been an important advance in the management of hypertension. As antihypertensive agents, the CCBs thus appear considerably more versatile than most previous vasodilators. The available studies indicate that CCBs are metabolically neutral and do not exacerbate dyslipidemia or impair glucose tolerance. In contrast to diuretics and beta-blockers, CCBs do not appear to alter insulin sensitivity. The CCBs also differ from previous vasodilators because of their favorable accompanying effects on the heart and kidney. Despite the attributes of CCBs enumerated earlier, a number of recent retrospective analyses by Psaty et al. (JAMA 1995;274:620-625) have suggested that CCBs may be detrimental and may promote adverse cardiovascular events. I have recently reviewed the results of Psaty's meta-analysis and report (Arch Intern Med 1995;155: 2150-2156). I have emphasized that it is the rate of drug delivery into the systemic circulation that produces profound effects on the hemodynamic and neurohumoral responses to a dihydropyridine CCB drug. During chronic treatment with dihydropyridines, major fluctuations in blood pressure (rapid onset and offset of antihypertensive effects) during the dosing interval may persist for drugs and formulations that are short acting. In contrast, slow-release formulations of otherwise rapidly absorbed dihydropyridines achieve a more gradual and sustained antihypertensive effect. It is probable that newer CCB formulations that do not provoke intermittent sympathetic activation and do not evoke a cardioacceleratory response would not be expected to promote adverse cardiovascular events.

Antihypertensive Agents↗
PubMed1997

Theoretical considerations on myofibril stiffness.

A discrete model of the interaction between individual myofilaments was developed to study the stiffness of a sarcomere for the case in which filament compliance is not negligible. Our model retains, in the limit, the characteristics of the previously published model by Ford et al. (Ford, L. E., A. F. Huxley, and R. M. Simmons. 1981. The relation between stiffness and filament overlap in stimulated frog muscle fibres. J. Physiol. 311:219-249). In addition, the model is able to model the interaction in cases in which few cross-bridges are attached, or when the distribution of attached cross-bridges is not uniform. Our results confirm previous indications that it might be impossible to calculate the number of attached cross-bridges by using only stiffness measurements in quick-stretch (or release) experiments.

Actins↗
PubMed1997

An improved solution for the contact of two biphasic cartilage layers.

The purpose of this study was to present a solution for the contact of two biphasic cartilage layers which can be used for dynamic loading, is not restricted to predictions over small time periods, and predicts biologically meaningful changes in contact areas over time. The proposed solution was based on the work of Ateshian et al. (1994, J. Biomechanics 27, 1347-1360) who retained the first term of an asymptotic expansion and used an approximate integration which is valid for short time periods. The solution proposed here uses an exact integration, is valid over long time periods, and can be used for increasing loading. The new solution corrects a limitation of the work by Ateshian et al., which manifests itself immediately (i.e. at time t = 0+ s): the rate of change in the contact radius (and therefore, the contact area) is increasing in Ateshian et al.'s solution for a constant force, whereas it is decreasing in the new solution. An increasing rate of change in the contact radius suggests that the contact radius (area) is unbounded, and a steady-state solution cannot be reached, which is physically not correct for the contact of two joint surfaces. In the new solution, the contact radius reaches a steady-state value given sufficient time.

Biomechanical Phenomena↗
PubMed1997

The dorsalizing and neural inducing gene follistatin is an antagonist of BMP-4.

Specific signaling molecules play a pivotal role in the induction and specification of tissues during early vertebrate embryogenesis. BMP-4 specifies ventral mesoderm differentiation and inhibits neural induction in Xenopus, whereas three molecules secreted from the organizer, noggin, follistatin and chordin dorsalize mesoderm and promote neural induction. Here we report that follistatin antagonizes the activities of BMP-4 in frog embryos and mouse teratocarcinoma cells. In Xenopus embryos follistatin blocks the ventralizing effect of BMP-4. In mouse P19 cells follistatin promotes neural differentiation. BMP-4 antagonizes the action of follistatin and prevents neural differentiation. In addition we show that the follistatin and BMP-4 proteins can interact directly in vitro. These data provide evidence that follistatin might play a role in modulating BMP-4 activity in vivo.

Animals↗
PubMed1997

Are calcium antagonists proarrhythmic?

Clinical and experimental studies demonstrate that calcium (Ca2+) overload in myocardial cells is an important factor in the genesis of various serious arrhythmias. Calcium antagonists block voltage-dependent channels and thus reduce entry of Ca2+ into heart cells. Because of their specificity for atrioventricular nodal cells, verapamil and diltiazem are used clinically to treat supraventricular arrhythmias involving transmission in the atrioventricular node. These two drugs and the dihydropyridine (DHP) calcium antagonists have been shown to prevent ventricular ischemic and reperfusion arrhythmias in the laboratory. Despite these data indicating that calcium antagonists are antiarrhythmic, a recent controversy has raised the possibility that certain calcium antagonists are unsafe to use, especially for patients with coronary heart disease. Proarrhythmia has been proposed to be a mechanism contributing to potentially adverse outcomes. Although excessive concentrations of verapamil and diltiazem may cause sino-atrial nodal asystole and varying degrees of atrioventricular block, there is little direct evidence that this contributes to significant proarrhythmia, for example, ventricular tachyarrhythmias. Nonetheless, although it appears paradoxical that agents which block the entry of Ca2+ into heart cells may be considered arrhythmogenic, there are circumstances under which dosage with certain calcium antagonists potentially leads to myocardial Ca2+ overload. For example, bouts of neurohormonal activation brought about by calcium antagonist-induced abrupt reductions in blood pressure may be accompanied each time by significant beta-adrenergic-enhanced influx of Ca2+ through the L-type cardiac calcium channels. This elevates the intracellular Ca2+ concentration and disturbs Ca2+ regulation, especially in diseased hearts whose intracellular Ca2+ regulation has already been compromised, and might induce alterations in cardiac electrical activity. In the present article, interactions among cardiac calcium channels, classes of calcium antagonists, and specific formulations of certain antagonists are considered with respect to directly induced ventricular arrhythmogenesis. Indirect potentially proarrhythmic actions of the calcium antagonists are also discussed. We outline some of the many questions that remain to be answered with respect to the actions of DHP on the heart including that of whether beta-adrenergic stimulation modifies the degree of cardiac Ca2+ channel inhibition by DHP-type calcium antagonists.

Arrhythmias, Cardiac↗
PubMed1997

Ischemic renal disease: an emerging cause of chronic renal failure and end-stage renal disease.

Ischemic renal disease (IRD) is defined as a clinically important reduction in glomerular filtration rate or loss of renal parenchyma caused by hemodynamically significant renal artery stenosis. IRD is a common and often overlooked clinical entity that presents itself in the setting of extrarenal arteriosclerotic vascular disease in older individuals with azotemia. Eleven to 14% of end-stage renal disease (ESRD) cases are attributable to chronic IRD. A high percentage of patients entering ESRD programs are hypertensive. Many patients with a presumed diagnosis of hypertensive nephrosclerosis actually have undiagnosed ischemic nephropathy as the etiology of their ESRD. It is important for the clinician to identify IRD, because IRD is a potentially reversible cause of chronic renal failure in a hypertensive patient. Atherosclerotic renal artery disease is common among patients with coronary artery disease and aortic and peripheral vascular disease. Atherosclerotic renal artery disease is a progressive disorder, and its progression is associated with loss of renal mass and functioning. A decrease in glomerular filtration rate sufficient to cause an elevation of the serum creatinine concentration requires injury to both kidneys. Consequently, IRD can arise from one of two main clinical situations: bilateral hemodynamically significant renal artery stenosis leading to bilateral renal ischemia; and hemodynamically significant renal artery stenosis in a solitary functioning kidney, or in a kidney that is providing the majority of a patient's glomerular filtration. The primary reason for establishing the diagnosis of IRD is the hope that correction of a renal artery stenosis will lead to improvement of renal function, or a delay in progression to ESRD. There are six major clinical settings in which the clinician could suspect IRD: acute renal failure caused by the treatment of hypertension, especially with angiotensin converting enzyme inhibitors; progressive azotemia in a patient with known renovascular hypertension; acute pulmonary edema superimposed upon poorly controlled hypertension and renal failure; progressive azotemia in an elderly patient with refractory or severe hypertension; progressive azotemia in an elderly patient with evidence of atherosclerotic disease; and unexplained progressive azotemia in an elderly patient. Noninvasive testing modalities that have been used recently include the angiotensin converting enzyme inhibitor renal scan, duplex Doppler sonography, magnetic resonance angiography, and the spiral computed tomography. Treatment methods include percutaneous transluminal angioplasty, endovascular stenting, and surgical revascularization. The results of treatment for preservation of renal function have been encouraging, with stabilization or improvement in renal function observed in a significant proportion of cases.

Humans↗
PubMed1997

Intrarenal determinants of sodium retention in mild heart failure: effects of angiotensin-converting enzyme inhibition.

The onset and the mechanisms leading to Na+ retention in incipient congestive heart failure (CHF) have not been systematically investigated. To investigate renal Na+ handling in the early or mild stages of CHF, Na+ balance and renal clearances were assessed in 10 asymptomatic patients with idiopathic or ischemic dilated cardiomyopathy and mild heart failure (HF) off treatment (left ventricular ejection fraction, 29.7+/-2%) and in 10 matched normal subjects during a diet containing 100 mmol/d of NaCl and after 8 days of high salt intake (250 mmol/d). Six patients were studied again after 6 weeks of treatment with enalapril (5 mg/d P.O.). At the end of the high salt diet, in patients with mild HF the cumulative Na+ balance exceeded by 110 mmol that of normal subjects (F=3.86, P<.001). During high salt intake, renal plasma flow and glomerular filtration rate were similarly increased in both normal subjects and mild HF patients. In spite of comparable increases of filtered Na+ in the two groups, fractional excretion of Na+, fractional clearance of free water, and fractional excretion of K+ (indexes of distal delivery of Na+) increased in normal subjects and were reduced in patients with mild HF. During enalapril treatment, in the mild HF patients the cumulative Na+ balance was restored to normal; furthermore, enalapril significantly attenuated the abnormalities in the distal delivery of Na+. Our results indicate that a defective adaptation of Na+ reabsorption in the proximal nephron is associated with Na+ retention in response to increased salt intake in the early or mild stages of HF. These abnormalities of renal Na+ handling are largely reversed by enalapril.

Adult↗
PubMed1997

Randomized placebo-controlled clinical trial of high-dose interleukin-2 in combination with a soluble p75 tumor necrosis factor receptor immunoglobulin G chimera in patients with advanced melanoma and renal cell carcinoma.

PURPOSE: A randomized, double-blind, placebo-controlled trial was performed to compare the toxicity and biologic effects of treatment with high-dose intravenous (IV) bolus interleukin-2 (IL-2) plus the recombinant human soluble p75 tumor necrosis factor (TNF) receptor immunoglobulin G (IgG) chimera (rhuTNFR:Fc) with high-dose IL-2 alone in patients with advanced melanoma and renal cell carcinoma. PATIENTS AND METHODS: Twenty patients with advanced melanoma or renal cell carcinoma were randomized to receive IL-2 (Chiron, Emeryville, CA) 600,000 IU/kg every 8 hours on days 1 to 5 and 15 to 19 (maximum, 28 doses) combined with placebo or the rhuTNFR:Fc fusion protein (Immunex, Seattle, WA) 10 mg/m2 on days 1 and 15 and 5 mg/m2 on days 3, 5, 17, and 19. The impact of rhuTNFR:Fc on IL-2 toxicity and biologic effects was evaluated. RESULTS: No clinically significant difference in toxicity was observed in the two treatment arms. The adjusted median number of IL-2 doses administered during cycle 1 was 24.5 (range, seven to 28) and 21.5 (range, five to 27) for the placebo and rhuTNFR:Fc arms, respectively (P = .544). IL-2-induced TNF bioactivity, neutrophil chemotactic defect, and serum IL-6, IL-8, and IL-1 receptor antagonist (IL-1RA) induction were suppressed by rhuTNFR:Fc. Two of nine assessable patients (22%) on IL-2/placebo and three of 10 patients (30%) on IL-2/rhuTNFR:Fc responded. CONCLUSION: Despite evidence of in vitro neutralization of TNF functional activity and partial inhibition of other secondary biologic effects of IL-2, rhuTNFR:Fc does not reduce the clinical toxicity associated with high-dose IL-2 therapy. These results suggest that the toxicity and antitumor effects of IL-2 treatment are independent of circulating TNF.

Adult↗
PubMed1997

Patterning of the embryo along the anterior-posterior axis: the role of the caudal genes.

Patterning along the anterior-posterior axis takes place during gastrulation and early neurulation. Homeobox genes like Otx-2 and members of the Hox family have been implicated in this process. The caudal genes in Drosophila and C. elegans have been shown to determine posterior fates. In vertebrates, the caudal genes begin their expression during gastrulation and they take up a posterior position. By injecting sense and antisense RNA of the Xenopus caudal gene Xcad-2, we have studied a number of regulatory interactions among homeobox genes along the anterior-posterior axis. Initially, the Xcad-2 and Otx-2 genes are mutually repressed and, by late gastrulation, they mark the posterior- or anterior-most domains of the embryo, respectively. During late gastrulation and neurulation, Xcad-2 plays an additional regulatory function in relation to the Hox genes. Hox genes normally expressed anteriorly are repressed by Xcad-2 overexpression while those normally expressed posteriorly exhibit more anterior expression. The results show that the caudal genes are part of a posterior determining network which during early gastrulation functions in the subdivision of the embryo into anterior head and trunk domains. Later in gastrulation and neurulation these genes play a role in the patterning of the trunk region.

Animals↗
PubMed1997

Direct evidence that thromboxane mimetic U44069 preferentially constricts the afferent arteriole.

The thromboxane A2 (TXA2) mimetic U44069 has been demonstrated to reduce the GFR and filtration fraction of the normal isolated perfused rat kidney markedly, suggesting a predominant constriction of preglomerular vessels. To assess this possibility directly, effects of U44069 on the renal microvessels of the isolated perfused hydronephrotic kidney were examined. At 10(-6) mol/L, U44069 elicited a 27 +/- 2% decrease in afferent arteriolar (AA) diameter (from 18.8 +/- 0.3 to 13.7 +/- 0.3 micron, P < 0.001). In contrast, efferent arteriolar (EA) diameter decreased by only 9 +/- 1% (from 16.4 +/- 0.5 to 15.0 +/- 0.5 micron, P < 0.001). These effects on both AA and EA were completely reversed by the TXA2 receptor antagonist SQ29548. The calcium antagonist diltiazem reversed U44069-induced AA constriction by 83 +/- 5%. The U44069-induced EA constriction was insensitive to the vasodilator action of diltiazem at concentrations from 10(-8) to 10(-6) mol/L, but at 10(-5) mol/L, diltiazem increased the EA diameter significantly, albeit modestly. Nifedipine also reversed the U44069-induced AA constriction (81 +/- 7%), but failed to inhibit the EA constriction at concentrations from 10(-9) to 10(-6) mol/L. These findings constitute the first direct evidence that a TXA2 agonist preferentially constricts the afferent arteriole. Furthermore, the ability of both the calcium antagonist and SQ29548 to reverse the renal microvascular actions of TXA2 agonists suggests a potential utility of these agents in ameliorating TXA2-induced renal hemodynamic abnormalities.

Animals↗
PubMed1997

The underreporting of deaths of American Indian children in California, 1979 through 1993.

OBJECTIVES: This study linked birth and death certificates to determine misclassification of deaths of American Indian children in California. METHODS: Birth records for 1979 to 1993 were matched with mortality records through a computerized system. RESULTS: The number of deaths to American Indians was estimated to be three to four times greater than that reported on death certificates. Children in urban counties and those who died before 1987 were more likely to be misclassified. CONCLUSIONS: California death certificates identify less than one third of the deaths among American Indian children. Adjusting for racial misclassification provides a more accurate accounting of child mortality among American Indians.

Adolescent↗
PubMed1997

Lysophosphatidic acid and platelet-derived growth factor synergistically stimulate growth of cultured rat mesangial cells.

Lysophosphatidic acid (LPA) is a structurally simple, platelet-derived phospholipid, capable of eliciting a variety of physiological responses. We have demonstrated previously that LPA elicited a marked contractile response in rat mesangial cells (Inoue CN, Forster HG, Epstein M. Circ Res 77:888-896, 1995). In the present study, we examined the potential of this vasoactive substance to induce mesangial cell proliferation. Serum-starved quiescent rat mesangial cells were incubated with either LPA or in combination with platelet-derived growth factor (PDGF). DNA synthesis was assessed by [3H]thymidine incorporation after 24 hr, and cell numbers were determined at 0, 4, and 7 days. LPA- (1 nM-30 microM) stimulated mesangial cell DNA synthesis in a dose-dependent manner. The DNA synthesis stimulated by PDGF (1-100 ng/ml) was characterized by a bell-shaped response curve with a maximum at 40 ng/ml PDGF. The ability of LPA (30 microM) to synergize PDGF was observed over the entire range of PDGF concentrations (1-100 ng/ml). Under optimal concentrations of LPA/PDGF (30 microM40 ng/ml, respectively), mesangial cells displayed a 67-fold increase in [3H]thymidine incorporation, and a 1.9-fold (Day 4) and 2.5-fold (Day 7) increase in cell number as compared with that of quiescent mesangial cells. With an in vitro assay with myelin basic protein as the substrate, both LPA and PDGF induced stimulation of mitogen-activated protein (MAP) kinase activity. In addition, LPA augmented PDGF-induced increase in MAP kinase activity. In summary, these results demonstrate that LPA is mitogenic alone and also acts synergistically in combination with PDGF to promote mesangial cell proliferation. We postulate that these actions of LPA have the potential to play a crucial role in the mitogenic response of mesangial cells seen in a wide array of inflammatory and thrombotic glomerular disorders.

Animals↗
PubMed1997

Video-microscopic assessment of the role of tissue angiotensin-converting enzyme in the control of the renal microcirculation.

In the present study, we assessed the role of tissue angiotensin-converting enzyme as a determinant of intrarenal hemodynamics by using the angiotensin-converting enzyme inhibitor trandolaprilat and the angiotensin II receptor antagonist losartan. Afferent and efferent arteriolar diameters were measured with computer-assisted vessel imaging in isolated perfused hydronephrotic rat kidneys. In response to the addition of 1.0 nM angiotensin I, afferent arterioles constricted by 27.3 +/- 2.4% and efferent arterioles by 20.9 +/- 2.4%. These constrictions were similar to those observed after the administration of 0.3 nM angiotensin 11 (33.7 +/- 2.3% and 20.9 +/- 2.4% in afferent and efferent arterioles, respectively). Pretreatment with the angiotensin-converting enzyme inhibitor trandolaprilat (0.1-10 microM) blunted the angiotensin I-induced constriction of afferent arterioles (12.7 +/- 1.4%) and completely abolished the angiotensin I-induced constriction of efferent arterioles. Subsequent addition of angiotensin II to the perfusate resulted in a marked decrease of afferent (39.9 +/- 1.8%) and efferent (27.8 +/- 3.3%) arteriolar diameters. Pretreatment with the angiotensin II receptor antagonist losartan completely blocked the angiotensin I-induced constriction of both afferent and efferent arterioles. Collectively, these data suggest that angiotensin I affects renal microvessels through its conversion to angiotensin II, mediated by locally available tissue angiotensin-converting enzyme, which subserves the local control of the renal microcirculation.

Angiotensin I↗
PubMed1997

Diabetes and hypertension: the bad companions.

DIABETES AND HYPERTENSION: Diabetes mellitus and hypertension are interrelated diseases that strongly predispose people to atherosclerotic cardiovascular disease. Hypertension is about twice as frequent in individuals with diabetes as in those without. The prevalence of coexisting hypertension and diabetes appears to be increasing in industrialized nations because populations are aging, and both hypertension and non-insulin-dependent diabetes mellitus (NIDDM) increase with age. An estimated 35-75% of diabetic cardiovascular and renal complications can be attributed to hypertension. ESSENTIAL HYPERTENSION: Essential hypertension accounts for the majority of hypertension in individuals with diabetes, particularly those with NIDDM, who constitute over 90% of those with a dual diagnosis of diabetes and hypertension. Diabetic nephropathy, which occurs after 15 years of diabetes in one-third of those with insulin-dependent diabetes and 20% of those with NIDDM, is an important contributing factor to the development of hypertension in the diabetic. New investigations should focus increasingly on identifying appropriate antihypertensive agents that not only lower blood pressure but also reduce cardiovascular risk and retard the rate of progression of diabetic renal disease.

Diabetes Mellitus, Type 2↗
PubMed1997

Hepatorenal syndrome: emerging perspectives.

Progressive oliguric renal failure (designated hepatorenal syndrome) commonly complicates the course of patients with advanced hepatic disease. Despite the severe derangement of renal function and ominous prognosis when renal failure develops, minimal and inconsistent pathologic abnormalities of the kidneys are found at autopsy. Furthermore, the kidneys, if transplanted, are capable of normal function, which supports the concept that the renal failure is functional and potentially reversible. In contrast to patients with classical acute renal failure (ATN), hepatorenal syndrome patients manifest characteristic alterations of renal function including (1) relatively hyperosmolar urine; (2) high creatinine urine to plasma (U:P) ratio, and (3) a very low urine sodium concentration (< 10 mEq/L). During the past several years we have witnessed new insights into both the pathophysiology and the therapeutics of this syndrome. The application of new methodology such as tracer kinetics has more rigorously delineated the role of a number of pathogenic mechanisms, including activation of the sympathetic nervous system. The characterization of endothelin and nitric oxide-arginine pathway and their roles in biology and medicine has provided additional new insights with regard to the pathogenesis of hepatorenal syndrome. For example, nitric oxide has been proposed to constitute a mediator of both the hyperdynamic circulation and renal failure. Finally, recently initiated therapeutic approaches lend a note of optimism to the future management of a syndrome that is so often incompatible with recovery. These include the acceptance of orthotopic liver transplantation as definitive treatment for patients with end-stage liver disease and attempts to improve renal function by use of transjugular intrahepatic porto-systemic shunt. Hopefully, ongoing and future clinical trials will establish the precise contribution of each of these treatment modalities and their respective roles in the therapeutic armamentarium.

Clinical Trials as Topic↗
PubMed1997

Extracorporeal blood purification in the management of patients with hepatic failure.

With the increasing success of orthotopic liver transplantation, the time has come for a reassessment of the role of extracorporeal blood purification in the management of patients with liver failure. In those patients with combined liver and kidney failure, both standard hemodialysis and the newer continuous renal replacement therapies have been found to be helpful in maintaining fluid, electrolyte, and acid base balance. In those patients with liver failure but without kidney dysfunction, extracorporeal purification techniques have been found useful for the removal of hepatic toxins and in facilitating the replacement of clotting factors. This review will outline the rationale and documented utility of a wide variety of blood purification modalities used in the management of patients with liver failure.

Blood Chemical Analysis↗