No effect of insertion/ deletion polymorphism at the ACE locus on normal blood pressure level or variability

Angiotensin I-converting enzyme (ACE) cleaves angiotensin I to angiotensin II, which is the active component in the renin-angiotensin system (RAS). We have studied an insertion/deletion polymorphism in DNA at the ACE locus. In three different series comprising 140, 90 and 136 unrelated individuals we found no evidence of association between genotypes in this insertion/deletion (I/D) polymorphism and level of systolic or diastolic blood pressure. In two series of 130 and 88 monozygotic (MZ) twin pairs, respectively, there was no difference between genotypes in within-pair variation in systolic or diastolic blood pressure. Thus, in these series of healthy people, neither "level gene" nor "variability gene" effects of this insertion/deletion polymorphism were observed.     

Xbal polymorphism in DNA at the apolipoprotein B locus is associated with myocardial infarction (MI)

Bøhn M, Bakken A, Erikssen J, Berg K. Xbal polymorphism in DNA at the apolipoprotein B locus is associated with myocardial infarction (MI). Clin Genet 1993: 44: 241–248. © Munksgaard, 1993 High levels of low density lipoprotein (LDL) and its apolipoprotein B (apoB) are risk factors for atherosclerosis and myocardial infarction (MI). There is rich genetic polymorphism in apoB, first detected as the Ag allotypes of LDL, but today mostly examined at the DNA level. Genes contribute to the population variation in LDL and apoB levels and alleles in polymorphisms at the apoB locus are candidate genes with respect to control of lipid levels and susceptibility to atherosclerosis and MI. The Xbal polymorphism at the apoB locus, which involves the third base of threonin codon 2488 (ACC→ACT) without changing the amino acid sequence was examined in a case-control study comprising 238 survivors of myocardial infarction (MI) and 621 controls. In univariate analysis, frequencies of genotypes in this polymorphism were not statistically different between patients and controls of either sex. However, in multivariate logistic regression analysis, the odds ratio X - X - homozygotes (homozygotes for absence of restriction site) for having MI compared to the pooled group of heterozygotes and X + X + homozygotes (homozygotes for presence of restriction site) was 2.16 (p = 0.007), after adjustments for age, sex, and levels of apoB, high density lipoprotein (HDL) cholesterol (HDLC) and Lp(a) lipoprotein. It appeared that heterozygotes do not have increased risk, compared to the X + X + homozygotes. Stratification according to low or high levels of apoB, HDLC and Lp(a) lipoprotein, showed that the X - X - genotype was more common in patients than controls, in all subgroups. We conclude that the X - allele in double (but not in single) dose most probably increases the risk of MI. The increased risk is apparently not conferred by higher levels of total cholesterol, LDL or apoB, but through some variable or mechanism not closely related to traditional risk factors.     

Insertion /deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme and parental history of myocardial infarction

Bøhn M, Berge KE, Bakken A, Erikssen J, Berg K. Insertion/deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme and parental history of myocardial infarction.
Clin Genet 1993: 44: 298–301. © Munksgaard, 1993
One hundred and eighty-one male and 48 female myocardial infarction (MI) survivors and 172 male and 194 female controls were studied with respect to a possible association between premature parental MI (before age 61 years in mothers and/or before age 56 years in fathers) and an insertion/deletion (I/D) polymorphism in the gene encoding angiotensin I-converting enzyme (ACE). In the total series, the frequency of premature parental MI was 14% in the DD (homozygotes for the deletion (D) allele) genotypic group, 10.6% in the ID (heterozygotes) genotypic group and 6.1% in the II (homozygotes for the insertion (I) allele) genotypic group. In all males (male MI survivors and male controls combined), and in the total series, there was a significant excess of DD individuals as compared to II individuals among those with a parental history of premature MI (odds ratio 3.1 (p = 0.03) and 3.1 (p = 0.009), respectively). The ACE polymorphism may be an important genetic marker of MI risk and contribute to clustering of premature MI in families.     

Restriction site polymorphism at the LPA (Lp(a) apoliprotein; apoliprotein(a)) locus

A restriction site polymorphism in the Lp(a) apolipoprotein gene (the LPA gene) is reported. The basis for the polymorphism is presence or absence of an MspI restriction site that appears to be 3' to the last kringle IV structure of the gene. The "1" gene (presence of the restriction site) has a frequency of 0.316 and the "2" gene (absence of the restriction site) has a frequency of 0.684. Both members of each of 67 monozygotic (MZ) twin pairs had the same genotype and there was Mendelian segregation of the DNA variants in 40 families with a total of 75 children. There was a lower proportion of people with genotype 1-1 in the top quartile than in the 3 bottom quartiles of the population distribution of Lp(a) lipoprotein levels but the difference did not reach statistical significance.     

DNA polymorphism at the locus for human cholesteryl ester transfer protein (CETP) is associated with high density lipoprotein cholesterol and apolipoprotein levels

Cholesteryl ester transfer protein (CETP) is a protein involved in "reverse cholesterol transport" and it could play an important role in facilitating the removal of cholesteryl esters from peripheral tissues for transport to the liver or for transfer of cholesterol between plasma lipoprotein particles. Both functions may be relevant to susceptibility or resistance to atherosclerotic disease. We have studied 149 and 146 unrelated persons, respectively, for the A and B polymorphism at the CETP locus detectable with the restriction enzyme TaqI. The B system is by far the more polymorphic. A search for association with risk or "anti-risk" factor levels was conducted with the following quantitative parameters: total cholesterol, HDL cholesterol, triglycerides, apolipoprotein AI (apoA-I), apolipoprotein B (apoB) and Lp(a) lipoprotein levels. Highly significant differences in apoA-I concentration were found between the two categories of homozygotes in the B polymorphism. The association observed remained significant after multiplying the p value by the number of quantitative parameters used for the association tests. There was a dosage effect on the apoA-I level of genes in the B polymorphism. We conclude that the associations observed are likely to reflect true biological phenomena. The effect of CETP genes appeared to be limited to non-smokers.     

Apolipoproteins B and E, and angiotensin I-converting enzyme (ACE) genetic polymorphisms in Italian women with coronary artery disease (CAD) and their relationships with plasma lipid and apolipoprotein levels

The Xba I, Eco RI and the signal peptide insertion/deletion ( I/D ) polymorphic sites of APOB gene, the Cfo I polymorphic site of apolipoprotein E gene (APOE), and the insertion/deletion polymorphism of angiotensin I-converting enzyme (ACE) gene were studied using polymerase chain reaction (PCR) in 55 postmenopausal women with coronary artery disease (CAD) and in 119 control women of equivalent age. Patients and controls were recruited from the population of Rome, considered representative of Central and Southern Italy. There were no significant differences in allele frequencies between the two groups, though APOB X-, R- and I, APOE*3 , and ACE D alleles were slightly more frequent in the cases than in the controls. The patients did not differ from the controls for plasma total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, and apoAI values, while they presented significantly higher levels of triglycerides and apoB, and lower apoE levels. TC, apoE, and apoB quantitative values, adjusted for age, varied significantly among APOB Xba I and APOE genotypes. APOB X-X-genotype was associated in patients with a significantly lower mean TC concentration than the other two genotypes pooled together. APOE 3–2 genotype in the controls had significantly lower TC levels with respect to the other two pooled genotypic classes and higher apoE levels compared to 3–3 and 4–3 genotypes. In the patients, 3–2 genotype had significantly lower apoB levels than the pooled 3–3 and 4–3 class. We conclude that in the Italian women the DNA polymorphisms studied in this work do not seem to be important risk factors for CAD occurrence; that apoE quantitation could be another useful parameter to identify subjects at risk of CAD; and that APOB X -and APOE*2 are the alleles that most influence the interindividual plasma lipid variation among CAD female patients.     

The apolipoprotein B signal peptide insertion/deletion polymorphism is not associated with myocardial infarction in Norway

The three-amino acid insertion/deletion (I/D) polymorphism in the apoB signal peptide (27 amino acid versus 24 amino acid signal peptide) was evaluated as a possible risk factor for myocardial infarction (MI) in a case-control study population comprising 238 MI survivors and 547 controls. In controls, homozygotes for the deletion allele (DD) had the highest mean levels of both total cholesterol and low density lipoprotein (LDL) cholesterol (LDLC), the homozygotes for the insertion allele (II) had the lowest mean values, while the heterozygotes (ID) had intermediate mean levels (p < 0.05). In MI survivors, the trend was similar, but only differences in mean LDLC levels were statistically significant (p < 0.05). No differences in genotype frequencies were detected between cases and controls in univariate analysis or in multivariate logistic regression analysis. Despite the results from the lipid analyses, we conclude that the I/D polymorphism in the apoB signal peptide is unlikely to be of major importance for MI risk in relatively young Norwegians.     

The angiotensin-I converting enzyme I/D polymorphism is not associated with type 2 diabetes in individuals undergoing coronary angiography. (The Ludwigshafen Risk and Cardiovascular Health Study)

The deletion (D) allele of the angiotensin-I converting enzyme (ACE) is associated with higher ACE activity and has been implicated only recently in the pathogenesis of type 2 diabetes in Caucasian subjects. We have studied the ACE I/D polymorphism in 1054 patients with type 2 diabetes and in 2251 individuals without type 2 diabetes in Caucasians persons undergoing coronary angiography. Further parameters of glucose metabolism (fasting glucose, HbA1c, insulin, C-peptide, pro-insulin, and pancreatic beta-cell function) were analyzed according to the ACE I/D genotype in a subgroup of 2000 individuals in whom an oral glucose challenge was performed. The genotypes ACE II, ID, DD occurred at similar frequencies in patients with type 2 diabetes mellitus (21.0, 50.8, and 28.3%, respectively) compared to non-diabetic individuals (23.3, 49.2, and 27.5%, respectively). There was no association of the ACE D allele with all type 2 diabetes mellitus (OR 1.16, 95%CI, 0.94-1.43), nor with known (OR 1.28, 95% CI, 0.99-1.68) or newly diagnosed diabetes (OR 1.00, 95% CI, 0.75-1.32). These findings were not materially altered when we adjusted for age and gender, cardiovascular risk factors and anti-diabetic or cardiovascular medication. Further the ACE D-allele was not associated with angiographic coronary heart disease or myocardial infarction. The ACE I/D genotype is not associated with type 2 diabetes mellitus, glucose metabolism, coronary heart disease, or myocardial infarction.     

Normal genetic variation at the low density lipoprotein receptor (LDLR) locus influences cholesterol levels in children

The population of Czechoslovakia is at high risk of premature atherosclerosis. Normal DNA polymorphism at the low density lipoprotein receptor (LDLR) locus detectable with the restriction enzyme PvuII was analyzed in Czech children with a high or a low concentration of total serum cholesterol. The PvuII restriction site was found significantly more often in the low cholesterol group than in the high cholesterol group. Thus, normal genetic variation at the LDLR locus contributes to the population variation in cholesterol in children in the population studied.     

Insertion/deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme and myocardial infarction

Bøhn M, Berge KE, Bakken A, Erikssen J, Berg K. Insertion/deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme and myocardial infarction.
Clin Genet 1993: 44: 292–297. © Munksgaard, 1993
Male (n = 185) and female (n = 49) survivors of myocardial infarction (MI) below 56 and 61 years of age, respectively, were compared to 366 controls with respect to distribution of genotypes in an insertion/deletion (ID) polymorphism at the angiotensin I-converting enzyme (ACE) locus. The frequency of the DD genotype (homozygosity for the deletion allele) was significantly lower among male patients than controls (22.7% versus 34.9%, p = 0.011). In a "low-risk" group, defined as having less than the sex-specific, age-adjusted median values of body mass index (BMI) and apolipoprotein B (apoB), respectively, and absence of treatment with lipid-lowering drugs, the prevalence of the DD genotype was not statistically different between male patients and controls. In a male "high-risk" group (those individuals who had not been defined as "low-risk" subjects), the prevalence of the DD genotype was 20.9% in patients and 38.3% in controls (p = 0.002). In women, no significant differences in genotype frequencies between patients and controls were found in the whole sample or in any subgroup. These results appear to be at variance with data reported recently by Cambien et al. (1992). The difference may be due to chance, undetected selection biases, different gene-environment interactions between Norway and France or Ireland, or to preferential loss of DD individuals in our male "high-risk" group.     

Lp(a) lipoprotein is a major risk factor for cardiovascular disease: pathogenic mechanisms and clinical significance

The results of two previous and two recent studies of middle-aged males and females are presented to exemplify the clinical importance of lipoprotein (a) (Lp(a)) as a risk factor for atherosclerosis and coronary heart disease. In these studies various conventional and recently suggested risk factors were included and different methods for Lp(a) quantification were used. Lp(a) was a significant risk factor in all four studies. In the recent prospective case-control study, Lp(a) and cholesterol were found to act synergistically and predict primary acute myocardial infarction in Swedish males. A cholesterol level above 6.5 mmol/1 increased the risk of acute myocardial infarction if the Lp(a) level was above 200 mg/1. The plasma apo A-I level was a protective factor. In the other recent case-control study, an Lp(a) level above 500 mg/1 was a highly significant risk factor in Black and White US women with myocardial infarction or advanced coronary artery disease in addition to low density lipoprotein cholesterol levels above 130 mg/dl. A high apo A-I level was a protective factor. In these studies no other factors tested reached significance in multivariate logistic regression analysis. A hypothetical association between high Lp(a) levels and intracellular infection with Chlamydia pneumoniae is discussed. The results suggest that the Lp(a) level is useful in identifying high-risk individuals. Lowering low density lipoprotein cholesterol below 100 mg/dl (7lt;2.6 mmol/1) seems to be most important in both males and females with high-risk Lp(a) levels.     

Association of angiotensin-converting enzyme insertion/deletion polymorphism with obesity,cardiovascular risk factors and exercise-mediated changes in Korean women

This study examined whether the angiotensin-converting enzyme (ACE) insertion (I)/deletion (D) polymorphism is associated with obesity, cardiovascular risk factors and 12-week exercise-mediated changes in Korean women. A total of 105 subjects were divided into three groups as II, ID and DD genotype groups based upon ACE I/D genotypes. Body composition and cardiovascular risk factors were compared among the three groups, and the association of ACE I/D genotypes with obesity and hypertension was evaluated. Total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) levels were higher (P < 0.05) in the DD genotype than in II or ID genotypes. D allele frequency in ACE I/D gene had a higher (P = 0.063) trend in the hypertensive group than the normotensive group. The DD genotype had a trend to develop (odds ratio 4.032, P = 0.086) more hypertension than the II genotype. The II and ID genotypes showed a significant (P < 0.05) decrease in intima media thickness of the carotid artery after an exercise intervention, whereas the DD genotype showed an increase. In conclusion, there is a trend towards association of ACE I/D polymorphism with hypertension but not with obesity. Exercise-mediated changes did not differ significantly among genotypes except IMTCA.     

Apolipoprotein(a) phenotypes and lipoprotein(a) concentrations in patients with hyperthyroidism

Lipoprotein(a) [Lp(a)] is a low-density lipoprotein (LDL) particle in which apolipoprotein B-100 (apoB) is attached to a glycoprotein called apolipoprotein(a) [apo(a)]. Apo(a) has several genetically determined phenotypes differing in molecular weight, to which Lp(a) concentrations in plasma are inversely correlated. High plasma levels of Lp(a) are associated with atherosclerotic diseases. It is therefore of interest to study whether factors other than the apo(a) gene locus are involved in the regulation of Lp(a) concentrations. We measured plasma concentrations of Lp(a) and other lipoproteins and determined apo(a) phenotypes in 31 patients with hyperthyroidism, before and after the patients had become euthyroid by treatment. The mean concentration of LDL cholesterol rose from 2.67 to 3.88 mmol/l (P<0.01), apoB rose from 0.79 to 1.03 g/l (P<0.01), and the median Lp(a) concentration increased from 9.74 to 18.97 mg/dl (P<0.01) on treatment. Lp(a) concentrations were inversely associated to the size of the apo(a) molecule both before (P< 0.01) and after treatment (P<0.01). The increase in Lp(a) was significant patients with high molecular weight apo(a) phenotypes (n = 9; P<0.01) and in patients with low molecular weight apo(a) phenotypes (n=16; P< 0.01), but not in those with apo(a) null types (n = 6; P = 0.5). The low levels LDL cholesterol and apoB in untreated hyperthyroidism may result from increased LDL receptor activity. The increase in Lp(a) levels were not correlated with the increase in LDL cholesterol or apoB. Most other clinical evidence indicates that the LDL receptor is not important in Lp(a) catabolism, and we suggest that the low Lp(a) levels seen in thyroid hormone excess are caused by an inhibition of Lp(a) synthesis.Abbreviations Lp(a) lipoprotein(a) - apo(a) apolipoprotein(a) - apoB apolipoprotein B-100 - LDL low-density lipoprotein - HDL high-density lipoprotein - TG triglycerides - T ₄ thyroxine - T ₃ triiodothyronine - TSH thyrotropin     

Effect of low-density lipoprotein buoyant density and cholesterol content on the formation of lipoprotein(a) particles

Lipoprotein(a) [Lp(a)] is a unique lipoprotein which resembles low-density lipoprotein (LDL) both in lipid composition and the presence of apolipoprotein B-100 (apo B-100). Lp(a) is, however, distinguishable from LDL by the presence of an additional glycoprotein apolipoprotein(a) [apo(a)], which is covalently attached to apo B-100 by a single disulfide bond. It is now generally accepted that Lp(a) assembly is a two-step process in which the initial non covalent interaction between apo(a) and apo B-100 is mediated by the weak lysine binding sites present in kringle IV types 6, 7 and 8 of apo(a). In the present study, we have investigated the effect of LDL heterogeneity on Lp(a) assembly in a group of 111 individuals. The three parameters of LDL composition assessed in this study were the cholesterol content, the apo B content, and the relative flotation rate (a measure of LDL buoyancy and thus size). We found no correlation between the size of LDL particles and the extent of Lp(a) formation; a weak negative correlation was observed between cholesterol content of LDL and Lp(a) formation (P=0.042). This may suggest a role for free (i. e., surface-associated) cholesterol in the ability of LDL to form Lp(a) particles. Received: 1 June 2001 / Accepted: 2 July 2001     

广东汉族人群血管紧张素转换酶基因（ACE）多态性研究

目的：探讨中国广东汉族群体血管紧张素转换酶基因（ＡＣＥ）第１６内含子中２８７ｂｐ片段的插入／缺失多态性分布。方法：应用ＰＣＲ扩增技术检测２４４名广东籍汉族人ＡＣＥ基因型。结果：广东汉族群体中ＡＣＥ基因插入纯合型Ｉ／Ｉ占４１％;插入和缺失杂合型Ｉ／Ｄ占４０％,缺失纯合型Ｄ／Ｄ占１９％;Ｉ与Ｄ等位基因出现频率分别为０．６２和０．３９。经Ｘ２检验男女之间无显著性差异（Ｐ＞０．０５）。本组资料Ｉ／Ｉ、Ｉ／Ｄ、Ｄ／Ｄ型三种基因频率与中国汉族人群ＡＣＥ基因多态性分布比较均无显著性差异（Ｐ＞０．０５）与日本人群比较发现日本人与广东汉族人Ｉ／Ｉ、Ｉ／Ｄ、Ｄ／Ｄ三种基因分布频率均无显著性差异（Ｐ＞０．０５）。与欧洲英、法、德三国人群比较发现国人的Ｄ／Ｄ发生频率低于上述三国。Ｉ／Ｉ型发生频率则明显高于欧洲三国。结论：本组资料对ＡＣＥ基因Ｉ／Ｄ多态性分析可能有助于从基因水平对防治ＡＣＥ酶相关疾病进行前瞻性研究具有多方面的应用价值。     

Influence of the angiotensin-converting enzyme gene insertion/deletion polymorphism on lipoprotein/lipid response to gemfibrozil

Evidence suggests that fibrate therapy reduces the risk of recurrent coronary heart disease among men with low levels of high density lipoprotein cholesterol (HDL-C). Indirect observations and new possible biological pathways suggest that the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism might modulate the lipoprotein/lipid profile and its response to fibrate therapy. To assess the possible interaction between fibrate therapy and such variants on plasma lipid and lipoprotein levels, 65 dyslipidemic abdominally obese men were treated for 6 months with or without gemfibrozil (600 mg twice daily). No differences in baseline plasma lipid and lipoprotein levels were found between genotype groups except for the HDL(3)-C subfraction, which was higher in the DD group (p = 0.02). A two-way factorial ANOVA was used to evaluate the effect of the genotype (DD homozygotes vs I allele carriers), the treatment (placebo vs gemfibrozil), and the interaction between these two independent variables on changes observed in lipid and lipoprotein concentrations. A significant genotype-by-treatment interaction (p = 0.02) was found for the plasma HDL-C response to the intervention program. In fact, having the DD genotype and being treated with gemfibrozil had a synergical effect on HDL-C levels. The results of this study suggest that the ACE I/D polymorphism influences the effect of gemfibrozil on plasma HDL-C levels.     

Normal DNA polymorphism at the low density lipoprotein receptor (LDLR) locus associated with serum cholesterol level

A restriction fragment length polymorphism (RFLP) at the low density lipoprotein receptor (LDLR) locus detectable with the restriction enzyme PvuII exhibits association with total serum cholesterol level. People who are homozygous for absence of the PvuII restriction site have a significantly higher total cholesterol level than heterozygotes (the number of homozygotes for presence of the restriction site was too small to permit meaningful comparison). This difference is significant at the 2% level. Thus, this study of sex- and age-adjusted cholesterol levels in a sample of healthy people yields additional evidence and sustains our previous proposal that normal alleles at the LDLR locus contribute to the population variation in total cholesterol levels. Absence of the PvuII site appears to confer an odds ratio of approximately 2.7 for having a cholesterol level in the top quartile of the population distribution.     

Studies on the structure and function of the apolipoprotein(a) gene

Lp(a) is an LDL-like lipoprotein that is a major inherited risk factor for atherosclerosis. It is distinguished from Lp(a) by the addition of apolipoprotein(a). The gene structure of apolipoprotein(a) is homologous to plasminogen, and competition with plasminogen activity may account for some of the pathophysiology associated with Lp(a). Six highly related genes have now been identified, and at least four are found in close proximity in overlapping genomic clones. Studies have begun on the regulation of apolipoprotein (a) gene expression, and the human apolipoprotein(a) gene has been inserted into transgenic mice, where it leads to the development of arterial lesions.     

JCL roundtable—Lipoprotein(a): The emerging risk factor

Lipoprotein(a), or Lp(a), is a major risk factor for atherothrombotic events along with low-density lipoprotein cholesterol and, inversely, high-density lipoprotein cholesterol. Lp(a) also contributes to the progression of calcific aortic stenosis and to the rare occurrence of arterial thrombotic strokes without atherosclerosis in children and younger women. Much has been learned about the inheritance of Lp(a) levels and the relationship between apolipoprotein(a) structure and function. Recent work suggests an intriguing interaction between oxidized phospholipids on Lp(a) and inflammatory interleukin-1 genotypes. New pharmaceutical approaches with antisense and RNA interference technology may achieve up to 90% lowering of Lp(a). This Roundtable includes practical considerations for clinically measuring and responding to Lp(a) levels.     

Influence of a functional polymorphism within the angiotensin I-converting enzyme gene on partial sleep deprivation in patients with major depression

Partial sleep deprivation (PSD) exerts transient antidepressant efficacy. As a potential mechanism of action an enhancement of dopaminergic neurotransmission within the CNS is discussed. Because genetic variations influencing neurotransmission could have an impact on therapeutic outcome and stability of improvement, we investigated the functional insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene to examine a possible influence on the dopaminergic pathway. We included 56 patients with major depression (DSM-IV). Psychiatric ratings including the HAM-D6 scale were assessed prior to and after PSD and related to the different genotypes. The ACE I/D polymorphism was determined following PCR amplification using genomic DNA. A total of 58.1% of the patients were PSD responders. As expected, the therapeutical effect of PSD was transient and most patients experienced an exacerbation of depressive symptoms on day 2. Subdivision according ACE gene variants showed a significantly less pronounced relapse of symptoms in ACE gene D-allele carriers (P=0.02). Our results give first hints that the ACE I/I genotype, probably influencing dopaminergic neurotransmission, could be an indicator for relapse after PSD. This should result in earlier and more intense additional therapeutic interventions in this group of patients.