Published online before print April 15, 2002, doi: 10.1161/01.CIR.0000015857.31889.7B
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2002;105:2159.)
© 2002 American Heart Association, Inc.
Clinical Investigation and Reports |
Efficacy and Safety of a Novel Cholesteryl Ester Transfer Protein Inhibitor, JTT-705, in Humans
A Randomized Phase II Dose-Response Study
From the Department of Vascular Medicine (G.J.d.G., J.A.K., J.J.P.K.) and Department of Statistics (A.H.Z.), Academic Medical Center, University of Amsterdam; Department of General Internal Medicine, University Medical Center (A.F.H.S., J.d.G.), Nijmegen; Department of Cardiology, Martini Hospital (J.L.P.), Groningen; and Cardiovascular Research Institute COEUR Biochemistry, Erasmus University (A.v.T.), Rotterdam, the Netherlands.
Correspondence to Dr J.J.P. Kastelein, Department of Vascular Medicine G1-146, Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, The Netherlands. E-mail e.vandongen{at}amc.uva.nl
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background— Cholesteryl ester transfer protein (CETP) mediates the transfer of neutral lipids between lipoproteins. High plasma levels of CETP are correlated with low HDL cholesterol levels, a strong risk factor for coronary artery disease. In earlier studies, JTT-705, a novel CETP inhibitor, was shown to increase plasma HDL cholesterol and to inhibit the progression of atherosclerosis in cholesterol-fed rabbits. This study describes the first results using this CETP inhibitor in humans.
Methods and Results— In a randomized, double-blind, and placebo-controlled trial, we evaluated the efficacy and safety of daily treatment with 300, 600, and 900 mg JTT-705 in 198 healthy subjects with mild hyperlipidemia. Treatment with 900 mg JTT-705 for 4 weeks led to a 37% decrease in CETP activity (P<0.0001), a 34% increase in HDL cholesterol (P<0.0001), and a 7% decrease in LDL cholesterol (P=0.017), whereas levels of triglycerides, phospholipid transfer protein, and lecithin-cholesterol acyltransferase were unaffected. In line with the increase of total HDL, a rise of HDL2, HDL3, and apolipoprotein A-I was also noted. JTT-705 showed no toxicity with regard to physical examination and routine laboratory tests.
Conclusions— We show that the use of the CETP inhibitor JTT-705 in humans is an effective means to raise HDL cholesterol levels with minor gastrointestinal side effects (P=0.06). Although these results hold promise, further studies are needed to investigate whether the observed increase in HDL cholesterol translates into a concomitant reduction in coronary artery disease risk.
Key Words: cholesterol • lipoproteins • atherosclerosis • cardiovascular diseases
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Therapeutic intervention to raise HDL cholesterol (HDL-C) for protection against coronary artery disease has regained significant interest.1 In this quest for novel drugs, cholesteryl ester transfer protein (CETP) represents an important target because this plasma protein plays a key role in HDL metabolism.2 The latter is highlighted by the discovery that genetic CETP deficiency is the main cause of high HDL-C in Asian populations.3 In principle, by raising HDL-C levels, we aim to prevent coronary artery disease; however, the mechanisms by which this may occur are still under discussion.4 HDL mediates the transport of excess cholesterol from the periphery (including the arterial wall) to the liver. This process of reverse cholesterol transport5 is often invoked to explain the atheroprotective effect of HDL. But HDL also is suggested to ameliorate vascular function and to protect against oxidative damage.6 In human lipoprotein metabolism, CETP mediates the transfer of cholesteryl esters from HDL to apolipoprotein (apo) B–containing particles in exchange for triglycerides. Thus, the use of CETP inhibition as a tool to raise HDL-C likely will not only affect reverse cholesterol transport but also influence other functions that are attributed to both HDL and LDL particles.
Despite the above uncertainties, the inverse association between CETP activity and HDL-C levels suggests that pharmacological inhibition of CETP may be warranted and crucial to improve our understanding of the role of this protein in atherogenesis. Various successful strategies already have been developed to inhibit plasma CETP activity.7–9 CETP antibodies can inhibit CETP activity and increase HDL-C in hamsters.10 Also, antisense oligodeoxynucleotides against CETP mRNA, as well as a vaccine that elicits antibodies that block CETP function, lead to significant increases in HDL-C, accompanied by a marked reduction of aortic cholesterol content in rabbits.11,12
Among others, these insights have led to the development of JTT-705, a compound that inhibits CETP activity by forming a disulphide bond with this protein. In cholesterol-fed rabbits, JTT-705 increased plasma HDL-C, decreased non–HDL-C and, importantly, resulted in a 70% decrease of aortic arch lesions.13 The drug was further tested in 3 phase I studies: In a single-dose study (100 to 1800 mg per day), the drug was well tolerated and did not result in significant toxicity in healthy white men. A 2-period crossover bioavailability study revealed that JTT-705 induced more pronounced CETP inhibition in the postprandial phase compared with the fasted state. In a 14-day multiple-dosing study, daily administration of 600 and 900 mg JTT-705 led to an increase of HDL-C and a decrease of LDL cholesterol (LDL-C) compared with placebo.
In this extended phase II study, we present the results of the safety and efficacy assessment after 4-week treatment with 300, 600, or 900 mg JTT-705 per day in healthy individuals with mild dyslipidemia.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients
The study cohort consisted of healthy individuals (134 men and 64 women), age 18 to 65 years, with HDL-C levels
1.6 mmol/L and triglyceride levels 4.5 mmol/L (there were no exclusion criteria for LDL-C). The following exclusion criteria were used: genetic hyperlipidemia; recent onset (within 6 months) of vascular disease (eg, unstable angina, myocardial infarction); women capable of childbearing without adequate birth control; significant comorbid illnesses, such as malignancy, diabetes mellitus, hypothyroidism, hepatic, or renal disease; alcohol abuse; and use of steroids, thiazide-diuretics, antiepileptics, oral contraceptives containing 
30 µg estrogen, and cholesterol-lowering agents. Concomitant medication (including ß-blockers) was permitted, but only if the dosage was not changed during the study period. All randomized individuals who received 1 daily dose of the study medication were included in the analysis.
Trial Design
The study was designed as a 12-week, multicenter, randomized, double-blind, and placebo-controlled trial, evaluating the efficacy and safety of 300, 600, or 900 mg JTT-705 per day. A run-in period of 4 weeks (visits 1 and 2) was followed by 4 weeks of treatment (visits 3, 4, and 5) and 4 weeks of monitoring (visit 6). Participants who used cholesterol-lowering treatment were taken off this medication at visit 1. Participants meeting all criteria at the baseline visit (visit 2) were allocated to placebo or to 300, 600, or 900 mg JTT-705 per day. Blood samples were drawn after an overnight fast. For CETP activity assays, blood was drawn before drug intake and during and after treatment (weeks 2, 3, 4, 5, and 6). Phospholipid transfer protein (PLTP) activity and lecithin-cholesterol acyltransferase (LCAT) activity were determined in 41 individuals (10 per group) before and after 4 weeks of treatment. The counting of returned tablets and empty packages was used to monitor compliance. The ethics committees of all participating centers approved the trial, and all participants gave informed consent.
Laboratory Analyses
Biochemistry, hematology, lipids, and lipoprotein analyses were performed at the central laboratory of CRL Europe in Belgium. Total cholesterol and triglycerides were measured by established enzymatic methods (Reagents Boehringer Mannheim and Technicon USA). HDL-C was determined with a heparin MnCl2 precipitation reagent,14 and LDL-C was calculated by the Friedewald formula.15 Serum HDL subfractions were determined by serial ultracentrifugation, and apolipoproteins were measured using an established immunonephelometric method (Reagents Dade Behring). CETP activity, CETP concentrations, PLTP activity, and LCAT activity were measured as described elsewhere.16–19 For the CETP measurements, plasma from 3 healthy adults was used as control. For PLTP and LCAT activities, human reference pool plasma was obtained by mixing equal amounts of plasma, isolated at 4°C from 250 healthy blood donors.
Safety Parameters
Safety monitoring included physical examination (including vital signs, weight, and waist circumference); ECG; and routine hematology, biochemistry (including ASAT, ALAT, and creatinin), and urinalysis.
Statistical Analyses
Differences between intervention groups at baseline were evaluated by the 
2 test for categorical variables and by the t test for continuous variables. For each treatment group, the absolute changes from baseline lipids, apolipoproteins, and values for lipoprotein-modifying proteins were reported as mean±SD. Analysis was done by fitting an ANOVA model with separate treatment effects for the 4 groups.
Safety analyses included all patients who signed the consent form and entered the run-in period. A 2 test was used for statistical analyses of the gastrointestinal adverse events. Statistical analyses were performed with SAS software (SAS Institute Inc).
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients
The total study cohort consisted of 198 participants who were randomized to placebo or to 300 mg (low dose), 600 mg (medium dose), or 900 mg (high dose) JTT-705 per day for 4 weeks (Figure 1). The majority of the randomized individuals were men, but each treatment group showed a similar male-to-female ratio (ie, 2:1). At baseline, the 4 groups did not show statistically significant differences with respect to demographic characteristics, lipids, lipoproteins, apolipoproteins, CETP activity, CETP concentration, PLTP, and LCAT activities (Table 1).
|
|
Effects of JTT-705
Cholesteryl Ester Transfer Protein
A clear dose-dependent decrease in CETP activity was observed after 1 week of treatment, reaching a maximum decrease of 37.2% (P<0.0001) from baseline after 4 weeks in the high-dose group (Figure 2). This decrease was accompanied by a significant (dose-dependent) increase in CETP concentration of 66.8% (P<0.0001) in the high-dose group (Figure 2). In contrast, PLTP and LCAT activities were not influenced by JTT-705 (Table 2).
|
|
Lipids, Lipoproteins, and Apolipoproteins
Table 2 provides the changes in these parameters after 4 weeks of treatment, and the effects of placebo and of 300, 600, and 900 mg JTT-705 on HDL-C, LDL-C, total cholesterol, and triglycerides over time are illustrated in Figure 3.
|
In the groups on active drug, we observed a dose-dependent increase in HDL-C, reaching a plateau after the first week. The additional effect of 900 mg JTT-705 over 600 mg on HDL-C was only apparent after 4 weeks of treatment at an increase of 33.9% (see Figure 3, top left). The overall rise in HDL-C was caused by significant increases in both HDL2 and HDL3 in all treatment groups (in the low-dose group, this did not reach statistical significance for HDL2; Table 2). The increase in HDL2 was dose dependent over the explored dose range, whereas the rise in HDL3 reached a plateau at 300 mg JTT-705 (Table 2). The effect of JTT-705 on HDL-C was not correlated with baseline HDL-C (P=0.75, Figure 4B). The rise in HDL-C also was accompanied by significant increases in both apoA-I and apoA-II levels in all treatment groups.
|
We also recorded a decrease of LDL-C levels in all treatment groups, reaching statistical significance in the high-dose group (-7.4%, P=0.012). As shown in Figure 4, the cholesterol-lowering effect of JTT-705 was correlated positively with baseline LDL-C levels (P=0.03, Figure 4A). ApoB, apoE, total cholesterol, and triglyceride levels were not significantly changed by JTT-705 dosages up to 900 mg per day. The atherogenicity index, represented by total cholesterol/HDL-C ratios, was significantly reduced in all 3 active groups compared with the placebo group.
Safety and Adverse Effects
Dosages up to 900 mg of JTT-705 were well tolerated and exhibited a clean safety profile. During and after the study, we observed no significant changes in vital signs. Also, there were no changes in body mass index, waist circumference, and blood pressure or signs of hepatocellular injury or renal damage. Eight abnormal hematological parameters were found (low hemoglobin, low red/white blood cell counts, and low reticulocyte counts) in 6 individuals: 3 occurred in the placebo group, 3 in the 300-mg group (during treatment), and 2 in the 900-mg group (before treatment started). In the follow-up period, 5 individuals discontinued intervention: 2 complained of migraine (1 was on placebo), 1 had a mild rash, and 2 developed hypertension.
JTT-705 may have mild gastrointestinal side effects, illustrated by the occurrence of diarrhea (5, 4, 3, and 2 individuals in the 900-, 600-, and 300-mg groups and placebo group, respectively), flatulence (2, 2, 3, and 1 individuals in the 900-, 600-, and 300-mg groups and placebo group, respectively), nausea (3, 2, 2, and 0 in the 900-, 600-, and 300-mg groups and placebo group, respectively), and constipation (1 person in each group). Although not statistically significant, the 900-mg dose was associated with a nonsignificant higher frequency of gastrointestinal complaints (P=0.058) after 4 weeks of treatment, as presented in Table 3. There were no withdrawals for gastrointestinal complaints.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Low plasma HDL-C is an independent risk factor for cardiovascular disease.20 In fact, a 1% increase of plasma HDL-C levels is reported to be associated with a 2% to 3% decrease in cardiovascular morbidity and mortality.21 Nevertheless, no good treatment option exists for patients with low HDL-C at this moment. Diet and moderate exercise are ineffective for significantly raising HDL-C,22 whereas the use of HMG-CoA reductase inhibitors and fibrates only confer a 5% to 15% increase in HDL-C.1,23 Nicotinic acid does increase HDL-C by 30% on a 3- to 4-g daily dose, but this drug has side effects that limit its use.24 Conversely, in this study, a novel CETP inhibitor, JTT-705, was shown to effectively raise HDL-C (up to 34%) and apoA-I (up to 16%) with only mild gastrointestinal side effects (P=0.058), although the dosage needed to achieve this effect was rather high (900 mg/d). It is important to note that inhibition of CETP by JTT-705 was accompanied by unchanged PLTP and LCAT activities, underlining the specificity of this drug. These phase II data are also consistent with the phase I data inasmuch as there were no serious adverse events or clinically relevant changes in safety parameters. Some mild gastrointestinal effects were observed, but no withdrawals occurred for that reason.
The rise in HDL-C levels was caused by significant increases in both HDL2 and HDL3 subfractions, but at higher dosages, HDL3 seemed to reach a plateau, whereas HDL2 still increased. Although CETP inhibition was anticipated to result in a rise in large cholesterol-rich HDL2, the observed rise in HDL3 is interesting. The latter may, in part, be explained by processing of HDL2 through PLTP and hepatic lipase activities, whereby smaller, less cholesterol-rich HDL particles are generated.
The literature on these HDL subfractions is unclear with regard to their biological effects, but most of the evidence indicates that HDL2 represents the antiatherogenic fraction.25 Our data indicate therefore that JTT-705 has a favorable effect on HDL subfraction composition.
It is of interest to compare human genetic CETP deficiency with pharmacological inhibition of CETP. Absence of plasma CETP in homozygous CETP deficiency has been shown to result in very high HDL-C (2.5 to 3.5 times normal levels) and significant reductions in LDL-C concentrations.3 However, heterozygosity for CETP gene mutations resulting in 35% to 39% CETP concentration reductions, similar to those seen in the highest dose group of the present study, are associated with variable increases in HDL-C (10% to 32%) and LDL-C reductions (1% to 12%).3,26 Most of the variation may be explained through the effects of mild missense mutations such as D442G and severe non-sense mutations (Int14G
A). This is illustrated by the fact that heterozygosity for the latter mutation has largely the same effects on lipids and lipoproteins as observed for the highest dose group of the present analysis.
An effect not seen in genetic CETP deficiency is the profound dose-dependent increase in plasma CETP concentrations on JTT-705 treatment. One can speculate that the liver and/or adipose tissue is compensating for the loss of active protein by the secretion of more CETP into the plasma. However, Sugano et al12 have reported that CETP inhibition by the use of antisense oligodeoxynucleotides, by contrast, resulted in a decreased CETP concentration in rabbits. Thus, it seems more likely that the increase in CETP concentration as observed in the present analysis results from delayed clearance of the inactivated protein (CETP-JTT-705 complexes) by the liver.
In addition to an increase in HDL-C, we observed a significant decrease in LDL-C in the high-dose group. The positive correlation between CETP and LDL-C was described earlier in subjects with CETP gene mutations.3 A reduction in LDL-C is not unexpected in the context of a reduced flux of cholesteryl esters from HDL to LDL. The same effect is observed in individuals with high baseline LDL-C, such as patients suffering from familial hypercholesterolemia who also carry CETP gene mutations.27 This is in line with our observation that subjects with high baseline LDL-C present with higher reduction of LDL-C after using JTT-705.
The consequences of these increased HDL-C levels are unknown. Studies in rabbits, which develop high CETP plasma levels on a high-cholesterol diet,28 have shown that CETP inhibition by JTT-705 can protect against atherosclerosis.11–13 Studies in mice, which are CETP deficient by nature, however, showed that expression of human CETP can be either atherogenic29,30 or antiatherogenic.31 To date, the precise role of CETP in human atherogenesis and how its activity relates to coronary artery disease risk is still unclear,32,33 but JTT-705 is an effective tool to study these relations. End point or surrogate coronary artery disease marker trials have to clarify whether JTT-705 can reduce or prevent cardiovascular disease.
|
Acknowledgments |
|---|
This CETP inhibitor trial was sponsored by Japan Tobacco Inc, Tokyo, Japan. Orion Clinical Services Ltd, Slough, United Kingdom, managed the project. John J.P. Kastelein is an Established Investigator of the Dutch Heart Foundation (2000D039). Jan Albert Kuivenhoven is a postdoctoral fellow of the Dutch Heart Foundation (D98.001). We thank the following colleagues for recruitment of the participants: D.C.G. Basart, Westfries Hospital, Hoorn; L.H.J. van Kempen, Hospital Rijnstate, Arnhem; D.E. Grobbee, University Medical Center, Utrecht; J.J.C. Jonker, Andro Medical Research BV, Rotterdam; Dr Bulk, Andromed Noord, Groningen; A.J.M. Oude Ophuis, Canisius Hospital, Nijmegen; and I. Stoel, Albert Schweitzer Hospital, Dordrecht, the Netherlands.
Received December 13, 2001; revision received February 28, 2002; accepted February 28, 2002.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Gotto AM Jr. Low high-density lipoprotein cholesterol as a risk factor in coronary heart disease: a working group report. Circulation. 2001; 103: 2213–2218.
2. Fielding CJ, Fielding PE. Molecular physiology of reverse cholesterol transport. J Lipid Res. 1995; 36: 211–228.
3. Inazu A, Brown ML, Hesler CB, et al. Increased high-density lipoprotein levels caused by a common cholesteryl-ester transfer protein gene mutation. N Engl J Med. 1990; 323: 1234–1238.
4. von Eckardstein A, Nofer JR, Assmann G. High density lipoproteins and arteriosclerosis: role of cholesterol efflux and reverse cholesterol transport. Arterioscler Thromb Vasc Biol. 2001; 21: 13–27.
5. Glomset JA. The plasma lecithins: cholesterol acyltransferase reaction. J Lipid Res. 1968; 9: 155–167.
6. Watson AD, Berliner JA, Hama SY, et al. Protective effect of high-density lipoprotein associated paraoxonase: inhibition of the biological activity of minimally oxidized low density lipoprotein. J Clin Invest. 1995; 96: 2882–2891.
7. Bisgaier CL, Essenburg AD, Minton LL, et al. Cholesteryl ester transfer protein inhibition by PD 140195. Lipids. 1994; 29: 811–818.
8. Connolly DT, Witherbee BJ, Melton MA, et al. Stereospecific inhibition of CETP by chiral N, N-disubstituted trifluoro-3-amino-2-propanols. Biochemistry. 2000; 39: 13870–13879.
9. Kothari HV, Poirier KJ, Lee WH, et al. Inhibition of cholesterol ester transfer protein CGS 25159 and changes in lipoproteins in hamsters. Atherosclerosis. 1997; 128: 59–66.
10. Gaynor BJ, Sand T, Clark RW, et al. Inhibition of cholesteryl ester transfer protein activity in hamsters alters HDL lipid composition. Atherosclerosis. 1994; 110: 101–109.
11. Rittershaus CW, Miller DP, Thomas LJ, et al. Vaccine-induced antibodies inhibit CETP activity in vivo and reduce aortic lesions in a rabbit model of atherosclerosis. Arterioscler Thromb Vasc Biol. 2000; 20: 2106–2112.
12. Sugano M, Makino N, Sawada S, et al. Effect of antisense oligonucleotides against cholesteryl ester transfer protein on the development of atherosclerosis in cholesterol-fed rabbits. J Biol Chem. 1998; 273: 5033–5036.
13. Okamoto H, Yonemori F, Wakitani K, et al. A cholesteryl ester transfer protein inhibitor attenuates atherosclerosis in rabbits. Nature. 2000; 406: 203–207.
14. Warnick GR, Albers JJ. A comprehensive evaluation of the heparin-manganese precipitation procedure for estimating high-density lipoprotein cholesterol. J Lipid Res. 1978; 19: 65–76.
15. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972; 18: 499–502.
16. Tollefson JH, Albers JJ. Isolation, characterization, and assay of plasma lipid transfer proteins. Methods Enzymol. 1986; 129: 797–816.
17. Kato H, Nakanishi T, Arai H, et al. Purification, microheterogeneity, and stability of human lipid transfer protein. J Biol Chem. 1989; 264: 4082–4087.
18. Speijer H, Groener JE, van Ramshorst E, et al. Different locations of cholesteryl ester transfer protein and phospholipid transfer protein activities in plasma. Atherosclerosis. 1991; 90: 159–168.
19. Joles JA, Willekes-Koolschijn N, Scheek LM, et al. Lipoprotein phospholipid composition and LCAT activity in nephrotic and analbuminemic rats. Kidney Int. 1994; 46: 97–104.
20. Castelli WP, Garrison RJ, Wilson PW, et al. Incidence of coronary heart disease and lipoprotein cholesterol levels: the Framingham Study. JAMA. 1986; 256: 2835–2838.
21. Manninen V, Elo MO, Frick MH, et al. Lipid alterations and decline in the incidence of coronary heart disease in the Helsinki Heart Study. JAMA. 1988; 260: 641–651.
22. Stefanick ML, Mackey S, Sheehan M, et al. Effects of diet and exercise in men and postmenopausal women with low levels of HDL cholesterol and high levels of LDL cholesterol. N Engl J Med. 1998; 339: 12–20.
23. Rackley CE. Monotherapy with HMG-CoA reductase inhibitors and secondary prevention in coronary artery disease. Clin Cardiol. 1996; 19: 683–689.
24. King JM, Crouse JR, Terry JG, et al. Evaluation of effects of unmodified niacin on fasting and postprandial plasma lipids in normolipidemic men with hypoalphalipoproteinemia. Am J Med. 1994; 97: 323–331.
25. Freedman DS, Otvos JD, Jeyarajah EJ, et al. Relation of lipoprotein subclasses as measured by proton nuclear magnetic resonance spectroscopy to coronary artery disease. Arterioscler Thromb Vasc Biol. 1998; 18: 1046–1053.
26. Zhong S, Sharp DS, Grove JS, et al. Increased coronary heart disease in Japanese-American men with mutation in the cholesteryl ester transfer protein gene despite increased HDL levels. J Clin Invest. 1996; 97: 2917–2923.
27. Haraki T, Inazu A, Yagi K, et al. Clinical characteristics of double heterozygotes with familial hypercholesterolemia and cholesteryl ester transfer protein deficiency. Atherosclerosis. 1997; 132: 229–236.
28. Meijer GW, Demacker PN, van Tol A, et al. Plasma activities of lecithin: cholesterol acyltransferase, lipid transfer proteins and post-heparin lipases in inbred strains of rabbits. Biochem J. 1993; 293(pt 3): 729–734.
29. Marotti KR, Castle CK, Boyle TP, et al. Severe atherosclerosis in transgenic mice expressing simian cholesteryl ester transfer protein. Nature. 1993; 364: 73–75.
30. Plump AS, Masucci-Magoulas L, Bruce C, et al. Increased atherosclerosis in apoE and LDL receptor gene knock-out mice as a result of human cholesteryl ester transfer protein transgene expression. Arterioscler Thromb Vasc Biol. 1999; 19: 1105–1110.
31. Foger B, Chase M, Amar MJ, et al. Cholesteryl ester transfer protein corrects dysfunctional high density lipoproteins and reduces aortic atherosclerosis in lecithin cholesterol acyltransferase transgenic mice. J Biol Chem. 1999; 274: 36912–36920.
32. Inazu A, Koizumi J, Mabuchi H. Cholesteryl ester transfer protein and atherosclerosis. Curr Opin Lipidol. 2000; 11: 389–396.
33. Yamashita S, Sakai N, Hirano K, et al. Molecular genetics of plasma cholesteryl ester transfer protein. Curr Opin Lipidol. 1997; 8: 101–110.
This article has been cited by other articles:
 |
|
 |
|
  M. J. Chapman, W. Le Goff, M. Guerin, and A. Kontush Cholesteryl ester transfer protein: at the heart of the action of lipid-modulating therapy with statins, fibrates, niacin, and cholesteryl ester transfer protein inhibitors Eur. Heart J., October 12, 2009; (2009) ehp399v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Mancek-Keber, H. Gradisar, M. I. Pestana, G. M. de Tejada, and R. Jerala Free Thiol Group of MD-2 as the Target for Inhibition of the Lipopolysaccharide-induced Cell Activation J. Biol. Chem., July 17, 2009; 284(29): 19493 - 19500. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. G. Drew, S. J. Duffy, M. F. Formosa, A. K. Natoli, D. C. Henstridge, S. A. Penfold, W. G. Thomas, N. Mukhamedova, B. de Courten, J. M. Forbes, et al. High-Density Lipoprotein Modulates Glucose Metabolism in Patients With Type 2 Diabetes Mellitus Circulation, April 21, 2009; 119(15): 2103 - 2111. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Masson, X.-C. Jiang, L. Lagrost, and A. R. Tall The role of plasma lipid transfer proteins in lipoprotein metabolism and atherogenesis J. Lipid Res., April 1, 2009; 50(Supplement): S201 - S206. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Vergeer, M. L. Bots, S. I. van Leuven, D. C. Basart, E. J. Sijbrands, G. W. Evans, D. E. Grobbee, F. L. Visseren, A. F. Stalenhoef, E. S. Stroes, et al. Cholesteryl Ester Transfer Protein Inhibitor Torcetrapib and Off-Target Toxicity: A Pooled Analysis of the Rating Atherosclerotic Disease Change by Imaging With a New CETP Inhibitor (RADIANCE) Trials Circulation, December 9, 2008; 118(24): 2515 - 2522. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D J Hausenloy and D M Yellon Targeting residual cardiovascular risk: raising high-density lipoprotein cholesterol levels Postgrad. Med. J., November 1, 2008; 84(997): 590 - 598. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D J Hausenloy and D M Yellon Targeting residual cardiovascular risk: raising high-density lipoprotein cholesterol levels Heart, June 1, 2008; 94(6): 706 - 714. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. S. Millar, M. E. Brousseau, M. R. Diffenderfer, P. H. R. Barrett, F. K. Welty, J. S. Cohn, A. Wilson, M. L. Wolfe, C. Nartsupha, P. M. Schaefer, et al. Effects of the cholesteryl ester transfer protein inhibitor torcetrapib on VLDL apolipoprotein E metabolism J. Lipid Res., March 1, 2008; 49(3): 543 - 549. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Moerland, H. Samyn, T. van Gent, M. Jauhiainen, J. Metso, R. van Haperen, F. Grosveld, A. van Tol, and R. de Crom Atherogenic, enlarged, and dysfunctional HDL in human PLTP/apoA-I double transgenic mice J. Lipid Res., December 1, 2007; 48(12): 2622 - 2631. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. M. Singh, M. H. Shishehbor, and B. J. Ansell High-Density Lipoprotein as a Therapeutic Target: A Systematic Review JAMA, August 15, 2007; 298(7): 786 - 798. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. C. van der Hoogt, W. de Haan, M. Westerterp, M. Hoekstra, G. M. Dallinga-Thie, J. A. Romijn, H. M. G. Princen, J. W. Jukema, L. M. Havekes, and P. C. N. Rensen Fenofibrate increases HDL-cholesterol by reducing cholesteryl ester transfer protein expression J. Lipid Res., August 1, 2007; 48(8): 1763 - 1771. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Yvan-Charvet, F. Matsuura, N. Wang, M. J. Bamberger, T. Nguyen, F. Rinninger, X.-C. Jiang, C. L. Shear, and A. R. Tall Inhibition of Cholesteryl Ester Transfer Protein by Torcetrapib Modestly Increases Macrophage Cholesterol Efflux to HDL Arterioscler Thromb Vasc Biol, May 1, 2007; 27(5): 1132 - 1138. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. J.P. Kastelein, S. I. van Leuven, L. Burgess, G. W. Evans, J. A. Kuivenhoven, P. J. Barter, J. H. Revkin, D. E. Grobbee, W. A. Riley, C. L. Shear, et al. Effect of Torcetrapib on Carotid Atherosclerosis in Familial Hypercholesterolemia N. Engl. J. Med., April 19, 2007; 356(16): 1620 - 1630. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. E. Borggreve, H. L. Hillege, G. M. Dallinga-Thie, P. E. de Jong, B. H.R. Wolffenbuttel, D. E. Grobbee, A. van Tol, R. P.F. Dullaart, and on behalf of the PREVEND Study Group High plasma cholesteryl ester transfer protein levels may favour reduced incidence of cardiovascular events in men with low triglycerides Eur. Heart J., April 4, 2007; (2007) ehm062v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Popa, M. G. Netea, P. L. C. M. van Riel, J. W. M. van der Meer, and A. F. H. Stalenhoef The role of TNF-{alpha} in chronic inflammatory conditions, intermediary metabolism, and cardiovascular risk J. Lipid Res., April 1, 2007; 48(4): 751 - 762. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Eichinger, N. M. Pecheniuk, G. Hron, H. Deguchi, M. Schemper, P. A. Kyrle, and J. H. Griffin High-Density Lipoprotein and the Risk of Recurrent Venous Thromboembolism Circulation, March 27, 2007; 115(12): 1609 - 1614. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. R. Tall, L. Yvan-Charvet, and N. Wang The Failure of Torcetrapib: Was it the Molecule or the Mechanism? Arterioscler Thromb Vasc Biol, February 1, 2007; 27(2): 257 - 260. [Full Text] [PDF]
|
|
|
|
|
|
S. Waxman, F. Ishibashi, and J. E. Muller Detection and Treatment of Vulnerable Plaques and Vulnerable Patients: Novel Approaches to Prevention of Coronary Events Circulation, November 28, 2006; 114(22): 2390 - 2411. [Full Text] [PDF]
|
|
|
|
|
|
H. Zhou, Z. Li, M. R. Hojjati, D. Jang, T. P. Beyer, G. Cao, A. R. Tall, and X.-C. Jiang Adipose tissue-specific CETP expression in mice: impact on plasma lipoprotein metabolism J. Lipid Res., September 1, 2006; 47(9): 2011 - 2019. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Kontush and M. J. Chapman Functionally Defective High-Density Lipoprotein: A New Therapeutic Target at the Crossroads of Dyslipidemia, Inflammation, and Atherosclerosis Pharmacol. Rev., September 1, 2006; 58(3): 342 - 374. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. R Pedersen, G. Assmann, J.-P. Bassand, M J. Chapman, R. Erbel, and C. Sirtori Reducing residual cardiovascular risk: the relevance of raising high-density lipoprotein cholesterol in patients on cholesterol-lowering treatment Diabetes and Vascular Disease Research, September 1, 2006; 3(2_suppl): S1 - S12. [Abstract] [PDF]
|
|
|
|
|
|
J. S. Millar, M. E. Brousseau, M. R. Diffenderfer, P. Hugh, R. Barrett, F. K. Welty, A. Faruqi, M. L. Wolfe, C. Nartsupha, A. G. Digenio, et al. Effects of the Cholesteryl Ester Transfer Protein Inhibitor Torcetrapib on Apolipoprotein B100 Metabolism in Humans Arterioscler Thromb Vasc Biol, June 1, 2006; 26(6): 1350 - 1356. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. C.N. Rensen and L. M. Havekes Cholesteryl Ester Transfer Protein Inhibition: Effect on Reverse Cholesterol Transport? Arterioscler Thromb Vasc Biol, April 1, 2006; 26(4): 681 - 684. [Full Text] [PDF]
|
|
|
|
|
|
A. H.E.M. Klerkx, K. E. Harchaoui, W. A. van der Steeg, S. M. Boekholdt, E. S.G. Stroes, J. J.P. Kastelein, and J. A. Kuivenhoven Cholesteryl Ester Transfer Protein (CETP) Inhibition Beyond Raising High-Density Lipoprotein Cholesterol Levels: Pathways by Which Modulation of CETP Activity May Alter Atherogenesis Arterioscler Thromb Vasc Biol, April 1, 2006; 26(4): 706 - 715. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Watanabe, S. Soderlund, A. Soro-Paavonen, A. Hiukka, E. Leinonen, C. Alagona, R. Salonen, T.-P. Tuomainen, C. Ehnholm, M. Jauhiainen, et al. Decreased High-Density Lipoprotein (HDL) Particle Size, Pre{beta}-, and Large HDL Subspecies Concentration in Finnish Low-HDL Families: Relationship With Intima-Media Thickness Arterioscler Thromb Vasc Biol, April 1, 2006; 26(4): 897 - 902. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. W. Clark, R. B. Ruggeri, D. Cunningham, and M. J. Bamberger Description of the torcetrapib series of cholesteryl ester transfer protein inhibitors, including mechanism of action J. Lipid Res., March 1, 2006; 47(3): 537 - 552. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Duffy and D. J. Rader Emerging Therapies Targeting High-Density Lipoprotein Metabolism and Reverse Cholesterol Transport Circulation, February 28, 2006; 113(8): 1140 - 1150. [Full Text] [PDF]
|
|
|
|
 |
|
 P. J. Barter and J. J.P. Kastelein Targeting Cholesteryl Ester Transfer Protein for the Prevention and Management of Cardiovascular Disease J. Am. Coll. Cardiol., February 7, 2006; 47(3): 492 - 499. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Masson, J.-P. Pais de Barros, Z. Zak, T. Gautier, N. Le Guern, M. Assem, J. W. Chisholm, J. R. Paterniti Jr., and L. Lagrost Human apoA-I expression in CETP transgenic rats leads to lower levels of apoC-I in HDL and to magnification of CETP-mediated lipoprotein changes J. Lipid Res., February 1, 2006; 47(2): 356 - 365. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Ohashi, H. Mu, X. Wang, Q. Yao, and C. Chen Reverse cholesterol transport and cholesterol efflux in atherosclerosis QJM, December 1, 2005; 98(12): 845 - 856. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. de Vries, F. G. Perton, G. M. Dallinga-Thie, A. M. van Roon, B. H.R. Wolffenbuttel, A. van Tol, and R. P.F. Dullaart Plasma Cholesteryl Ester Transfer Is a Determinant of Intima-Media Thickness in Type 2 Diabetic and Nondiabetic Subjects: Role of CETP and Triglycerides Diabetes, December 1, 2005; 54(12): 3554 - 3559. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Dumont, T. Gautier, J.-P. P. de Barros, H. Laplanche, D. Blache, P. Ducoroy, J. Fruchart, J.-C. Fruchart, P. Gambert, D. Masson, et al. Molecular Mechanism of the Blockade of Plasma Cholesteryl Ester Transfer Protein by Its Physiological Inhibitor Apolipoprotein CI J. Biol. Chem., November 11, 2005; 280(45): 38108 - 38116. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Bisoendial, G. K. Hovingh, K. El Harchaoui, J. H.M. Levels, S. Tsimikas, K. Pu, A. E. Zwinderman, J. A. Kuivenhoven, J. J.P. Kastelein, and E. S.G. Stroes Consequences of Cholesteryl Ester Transfer Protein Inhibition in Patients With Familial Hypoalphalipoproteinemia Arterioscler Thromb Vasc Biol, September 1, 2005; 25(9): e133 - e134. [Full Text] [PDF]
|
|
|
|
|
|
G. K. Hovingh, B. A. Hutten, A. G. Holleboom, W. Petersen, P. Rol, A. Stalenhoef, A. H. Zwinderman, E. de Groot, J. J.P. Kastelein MD, and J. A. Kuivenhoven Compromised LCAT Function Is Associated With Increased Atherosclerosis Circulation, August 9, 2005; 112(6): 879 - 884. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. F. Lewis and D. J. Rader New Insights Into the Regulation of HDL Metabolism and Reverse Cholesterol Transport Circ. Res., June 24, 2005; 96(12): 1221 - 1232. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G D Kolovou, K K Anagnostopoulou, and D V Cokkinos Pathophysiology of dyslipidaemia in the metabolic syndrome Postgrad. Med. J., June 1, 2005; 81(956): 358 - 366. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. E. Brousseau, M. R. Diffenderfer, J. S. Millar, C. Nartsupha, B. F. Asztalos, F. K. Welty, M. L. Wolfe, M. Rudling, I. Bjorkhem, B. Angelin, et al. Effects of Cholesteryl Ester Transfer Protein Inhibition on High-Density Lipoprotein Subspecies, Apolipoprotein A-I Metabolism, and Fecal Sterol Excretion Arterioscler Thromb Vasc Biol, May 1, 2005; 25(5): 1057 - 1064. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. B. Lloyd, M. E. Lira, L. S. Wood, L. K. Durham, T. B. Freeman, G. M. Preston, X. Qiu, E. Sugarman, P. Bonnette, A. Lanzetti, et al. Cholesteryl Ester Transfer Protein Variants Have Differential Stability but Uniform Inhibition by Torcetrapib J. Biol. Chem., April 15, 2005; 280(15): 14918 - 14922. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. W. Burgess, T. A-M. Neville, P. Rouillard, Z. Harder, D. S. Beanlands, and D. L. Sparks Phosphatidylinositol increases HDL-C levels in humans J. Lipid Res., February 1, 2005; 46(2): 350 - 355. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. J. de Grooth, A. H. E. M. Klerkx, E. S. G. Stroes, A. F. H. Stalenhoef, J. J. P. Kastelein, and J. A. Kuivenhoven A review of CETP and its relation to atherosclerosis J. Lipid Res., November 1, 2004; 45(11): 1967 - 1974. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Madjid, A. Zarrabi, S. Litovsky, J. T. Willerson, and W. Casscells Finding Vulnerable Atherosclerotic Plaques: Is It Worth the Effort? Arterioscler Thromb Vasc Biol, October 1, 2004; 24(10): 1775 - 1782. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. B. Brewer Jr, A. T. Remaley, E. B. Neufeld, F. Basso, and C. Joyce Regulation of Plasma High-Density Lipoprotein Levels by the ABCA1 Transporter and the Emerging Role of High-Density Lipoprotein in the Treatment of Cardiovascular Disease Arterioscler Thromb Vasc Biol, October 1, 2004; 24(10): 1755 - 1760. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Zhang, P. Fan, E. Shimoji, H. Xu, K. Takeuchi, C. Bian, and K. Saku Inhibition of Cholesteryl Ester Transfer Protein Activity by JTT-705 Increases Apolipoprotein E-Containing High-Density Lipoprotein and Favorably Affects the Function and Enzyme Composition of High-Density Lipoprotein in Rabbits Arterioscler Thromb Vasc Biol, October 1, 2004; 24(10): 1910 - 1915. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. L. Wolfe and D. J. Rader Cholesteryl Ester Transfer Protein and Coronary Artery Disease: An Observation With Therapeutic Implications Circulation, September 14, 2004; 110(11): 1338 - 1340. [Full Text] [PDF]
|
|
|
|
|
|
S. M. Boekholdt, J.-A. Kuivenhoven, N. J. Wareham, R. J.G. Peters, J. W. Jukema, R. Luben, S. A. Bingham, N. E. Day, J. J.P. Kastelein, and K.-T. Khaw Plasma Levels of Cholesteryl Ester Transfer Protein and the Risk of Future Coronary Artery Disease in Apparently Healthy Men and Women: The Prospective EPIC (European Prospective Investigation into Cancer and nutrition)-Norfolk Population Study Circulation, September 14, 2004; 110(11): 1418 - 1423. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. F Watts Treating low HDL-cholesterol in normocholesterolaemic patients with coronary disease: statins, fibrates or horses for courses? Eur. Heart J., May 1, 2004; 25(9): 716 - 719. [Full Text] [PDF]
|
|
|
|
|
|
J. D. Curb, R. D. Abbott, B. L. Rodriguez, K. Masaki, R. Chen, D. S. Sharp, and A. R. Tall A prospective study of HDL-C and cholesteryl ester transfer protein gene mutations and the risk of coronary heart disease in the elderly J. Lipid Res., May 1, 2004; 45(5): 948 - 953. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. E. Brousseau, E. J. Schaefer, M. L. Wolfe, L. T. Bloedon, A. G. Digenio, R. W. Clark, J. P. Mancuso, and D. J. Rader Effects of an Inhibitor of Cholesteryl Ester Transfer Protein on HDL Cholesterol N. Engl. J. Med., April 8, 2004; 350(15): 1505 - 1515. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. F. Asztalos, K. V. Horvath, K. Kajinami, C. Nartsupha, C. E. Cox, M. Batista, E. J. Schaefer, A. Inazu, and H. Mabuchi Apolipoprotein composition of HDL in cholesteryl ester transfer protein deficiency J. Lipid Res., March 1, 2004; 45(3): 448 - 455. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Masson, B. Staels, T. Gautier, C. Desrumaux, A. Athias, N. Le Guern, M. Schneider, Z. Zak, L. Dumont, V. Deckert, et al. Cholesteryl ester transfer protein modulates the effect of liver X receptor agonists on cholesterol transport and excretion in the mouse J. Lipid Res., March 1, 2004; 45(3): 543 - 550. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. B. Brewer Jr. High-Density Lipoproteins: A New Potential Therapeutic Target for the Prevention of Cardiovascular Disease Arterioscler Thromb Vasc Biol, March 1, 2004; 24(3): 387 - 391. [Full Text]
|
|
|
|
|
|
R. W. Clark, T. A. Sutfin, R. B. Ruggeri, A. T. Willauer, E. D. Sugarman, G. Magnus-Aryitey, P. G. Cosgrove, T. M. Sand, R. T. Wester, J. A. Williams, et al. Raising High-Density Lipoprotein in Humans Through Inhibition of Cholesteryl Ester Transfer Protein: An Initial Multidose Study of Torcetrapib Arterioscler Thromb Vasc Biol, March 1, 2004; 24(3): 490 - 497. [Abstract] [Full Text]
|
|
|
|
|
|
V. M. Paromov and R. E. Morton Lipid Transfer Inhibitor Protein Defines the Participation of High Density Lipoprotein Subfractions in Lipid Transfer Reactions Mediated by Cholesterol Ester Transfer Protein (CETP) J. Biol. Chem., October 17, 2003; 278(42): 40859 - 40866. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Calabresi, M. Gomaraschi, and G. Franceschini Endothelial Protection by High-Density Lipoproteins: From Bench to Bedside Arterioscler Thromb Vasc Biol, October 1, 2003; 23(10): 1724 - 1731. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Le Goff, M. Guerin, L. Petit, M. J. Chapman, and J. Thillet Regulation of human CETP gene expression: role of SP1 and SP3 transcription factors at promoter sites -690, -629, and -37 J. Lipid Res., July 1, 2003; 44(7): 1322 - 1331. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Bisoendial, G. K. Hovingh, J. H.M. Levels, P. G. Lerch, I. Andresen, M. R. Hayden, J. J.P. Kastelein, and E. S.G. Stroes Restoration of Endothelial Function by Increasing High-Density Lipoprotein in Subjects With Isolated Low High-Density Lipoprotein Circulation, June 17, 2003; 107(23): 2944 - 2948. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Parini and L. L. Rudel Is There a Need for Cholesteryl Ester Transfer Protein Inhibition? Arterioscler Thromb Vasc Biol, March 1, 2003; 23(3): 374 - 375. [Full Text] [PDF]
|
|
|
|
|
|
P. J. Barter, H. B. Brewer Jr, M. J. Chapman, C. H. Hennekens, D. J. Rader, and A. R. Tall Cholesteryl Ester Transfer Protein: A Novel Target for Raising HDL and Inhibiting Atherosclerosis Arterioscler Thromb Vasc Biol, February 1, 2003; 23(2): 160 - 167. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. H.E.M. Klerkx, M. W.T. Tanck, J. J.P. Kastelein, H. O.F. Molhuizen, J. W. Jukema, A. H. Zwinderman, and J. A. Kuivenhoven Haplotype analysis of the CETP gene: not TaqIB, but the closely linked -629C->A polymorphism and a novel promoter variant are independently associated with CETP concentration Hum. Mol. Genet., January 15, 2003; 12(2): 111 - 123. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. C Fonarow Treating to goal: new strategies for initiating and optimizing lipid-lowering therapy in patients with atherosclerosis Vascular Medicine, August 1, 2002; 7(3): 187 - 194. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||