Statin Usage in Peripheral Arterial Disease Patients.

OBJECTIVES: Atherosclerotic cardiovascular disease (ASCVD) events have been shown to occur at higher frequency in patients with peripheral arterial disease (PAD). In this study, our aim is to evaluate whether statin is being used appropriately in patients with PAD and also evaluate its usage with the number of vascular beds involved. MATERIALS AND METHODS: This retrospective cross-sectional study reviewed data of patients with a confirmed diagnosis of PAD based on invasive or noninvasive imaging. Demographic, clinical, laboratory, and treatment data collected were described using descriptive statistics. Multiple logistic regression analysis was conducted to determine the predictors for the prescription of statins (HIS). High-intensity statin therapy was defined as atorvastatin ≥40 mg per day, rosuvastatin ≥20 mg per day, or simvastatin ≥80 mg per day, according to American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. RESULTS: We analyzed data from 166 patients who met the inclusion criteria. The mean age was 63.34 years. The most common comorbidity was diabetes mellitus (DM) (68.86%). Statins were used in 82% of patients, among whom only 39% were on high-intensity statins. Multiple logistic regression analysis revealed that patients with cerebrovascular disease (CVD) [odds ratio (OR) = 0.19, 95% confidence interval (CI) = 0.06-0.61, p = 0.005], on oral anticoagulants (OAC) (OR = 0.16, 95% CI = 0.04-0.62, p = 0.008) and on dual antiplatelet therapy (DAPT) (OR = 0.20, 95% CI = 0.08-0.47, p < 0.000) had lower odds of receiving lower extremity revascularization (LIS) therapy. CONCLUSION: Despite having a high risk of future adverse cardiac events, patients with PAD are less likely to receive appropriate statin therapy. Involvement of more vascular beds was associated with higher chances of initiating high-intensity statin.

Exploring the Efficacy of Sotagliflozin on Heart and Kidney Health in Diabetic Patients: A Comprehensive Meta-Analysis.

Evidence for reducing cardiovascular and renal events with sotagliflozin is uncertain among type 2 diabetes mellitus (T2DM) patients. To gather more evidence, this meta-analysis assesses the beneficial effects of sotagliflozin, a dual sodium-glucose cotransporter 1 and 2 inhibitor, in reducing the cardiovascular and renal events in diabetic patients with or without chronic kidney disease (CKD). Scopus, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were the databases used to search. The studies published from January 1, 2018, to January 30, 2022, were considered. The eligibility of studies was assessed independently. The data were collected in a modified Cochrane data extraction form. The included studies' quality was assessed with the Cochrane risk-of-bias tool. The quality of evidence for renal and cardiovascular outcomes was evaluated using GRADEpro software. The number of events of urgent visits to the hospital and requiring hospitalization was reduced (RR: 0.73; 95% CI: 0.69, 0.78; P value <0.00001). The mortality rate because of cardiovascular events was decreased with sotagliflozin (RR: 0.73; 95% CI: 0.67, 0.80; P value <0.00001). Patients taking sotagliflozin had a drastic decline in the number of deaths due to stroke and non-fatal myocardial infarction. Yet, there is no difference between the groups in terms of changes in mortality due to other causes or the glomerular filtration rate (GFR). Sotagliflozin demonstrated effectiveness in reducing the mortality rate related to heart failure and cardiovascular events when the dose was increased from 200 mg to 400 mg. Despite this, evidence is still needed to prove the renal protective action.

Systemic Review and Meta-Analysis to Evaluate Therapeutic Effectiveness of Interferon Beta-1b in Hospitalized COVID-19 Patients.

The COVID-19 pandemic has caused havoc in the health sector. Inflammatory cytokines play an important role in the disease condition. Existing evidence has provided certain insights into the repurposing of the drugs. This meta-analysis and systematic review aimed to explore the efficacy of the administration of interferon beta-1b (IFN ß-1b) and standard care versus only standard care as the therapeutic agent for managing COVID-19 patients who are severely ill. The search was conducted in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Scopus, and Google Scholar, which were published during the period January 1, 2020, to February 16, 2023. All the included three studies were independently assessed for eligibility. The modified data extraction form of Cochrane were used. The quality of the three included studies was assessed using the Cochrane risk of bias tool. GradePro software was used to summarize the quality grading of the primary outcome measures. The time taken for clinical improvement was (MD: -3.28 days; 95% CI: -5.65, -0.91; P value = 0.007) when treated with IFN ß-1b. The duration of hospital stays (MD: -2.43 days; 95% CI: -4.45, -0.30; P value = 0.03), and need for intensive care unit (ICU) admission (RR: 0.71; 95% CI: 0.52, 0.97; P value = 0.03) was statistically significant. Interferon beta-1b is proven to reduce the duration of hospital stay, and the improved clinical status may become a cornerstone of COVID-19 treatment.

Synthesis and Structure Refinement of [Co-Al4-X] LDHs (X = NO3 - and SO4 2-) from Nordstrandite.

[M-Al4-X] LDHs (M = divalent metal and X = anion) are a class of aluminum-rich layered double hydroxides synthesized from both the gibbsite and bayerite polymorphs of Al(OH)3. Henceforth, "g" and "b" are used to indicate gibbsite and bayerite. Despite the differences in the stacking arrangement of the hydroxyl layers in the precursor polymorphs, [M-Al4-X] LDHs whether synthesized from gibbsite or bayerite were seen to be structurally the same. In this work, we report the first ever synthesis of [M-Al4-X] LDHs (M = Zn, Ni, and Co and X = NO3 - and SO4 2-) from nordstrandite, which is yet another polymorph of Al(OH)3. Hereafter, "n" represents the nordstrandite precursor. We report that n-[M-Al4-X] LDHs do not differ structurally from those prepared from gibbsite and bayerite. We also report the structural refinement of n-[Co-Al4-X] LDHs, where X = NO3 - and SO4 2-. This work is also significant as it gives for the very first time the refined structure of a [Co-Al4-NO3] LDH, though there are earlier reports on the synthesis of this LDH from both gibbsite and bayerite. The NO3 - ion in the interlayer makes an angle of ∼48° with the plane of the metal hydroxide layer, and its symmetry reduces from D 3h to C 2v . Similarly, the change in the symmetry of the SO4 2- ion in the interlayer is from T d to C 3v .

Anti-cardiolipin IgG autoantibodies associate with circulating extracellular DNA in severe COVID-19.

Whereas the detection of antiphospholipid autoantibodies (aPL) in COVID-19 is of increasing interest, their role is still unclear. We analyzed a large aPL panel in 157 patients with COVID-19 according to the disease severity. We also investigated a potential association between aPL and extracellular DNA (exDNA, n = 85) or circulating markers of neutrophil extracellular traps (NET) such as citrullinated histones H3 (CitH3, n = 49). A total of 157 sera of patients infected by SARS-CoV-2 were collected. A large aPL panel including lupus anticoagulant, anti-cardiolipin and anti-beta-2 glycoprotein I (IgG, IgM and IgA), anti-phosphatidylethanolamine IgA, anti-prothrombin (IgG and IgM) was retrospectively analyzed according to the disease severity. We found a total aPL prevalence of 54.8% with almost half of the cases having aCL IgG. Within an extended panel of aPL, only aCL IgG were associated with COVID-19 severity. Additionally, severe patients displayed higher CitH3 levels than mild patients. Interestingly, we highlighted a significant association between the levels of aCL IgG and exDNA only in aCL positive patients with severe disease. In conclusion, we showed a significant link between aPL, namely aCL IgG, and circulating exDNA in patients with severe form of COVID-19, that could exacerbate the thrombo-inflammatory state related to disease severity.

Strengthening global midwifery education to improve quality maternity care: Co-designing the World Health Organization Midwifery Assessment Tool for Education (MATE).

AIMS: To describe a three-phase co-designed project to develop a culturally appropriate and relevant education assessment tool, and report on pilot and field-testing phases. BACKGROUND: High-quality midwifery education is essential for high-quality maternity care (WHO 2019); however midwifery education and maternity care vary in quality throughout Europe. To support countries in strengthening their midwifery education, World Health Organization (WHO) European Region commissioned development of the Midwifery Assessment Tool for Education (MATE). The tool was developed over three years, using an iterative, collaborative process with regional experts. Published by WHO in May 2020, MATE provides focused questions and evidence-informed resources to stimulate and inform discussions within country. DESIGN: Three-phase co-design approach to develop, pilot and field-test an education assessment tool. METHODS: Phase 1: initial development of MATE with expert midwifery support; Phase 2: MATE piloting workshops in Czech Republic and Lithuania focusing on clarity, usability and relevance; Phase 3: MATE field-testing workshop in Bulgaria exploring the process of using MATE and its effectiveness for generating discussion. Purposive selection of workshop participants ensured a broad range of perspectives: clinicians, educators, students, policy makers and service users. All participants were invited to give narrative feedback during workshops and via completion of a post-workshop online survey. The XX University Research Ethics Committee advised that formal ethical review was unnecessary. RESULTS: Feedback from collaborators in all phases indicated that engaging with MATE co-design and testing was a positive experience. A 'bottoms up' approach ensured that MATE content was relevant to regional needs, culturally acceptable and appropriate. Seventy-nine individuals participated in Phases 2 and 3 and all were sent a post-workshop online survey, with 31 responses (39 %). Qualitative and quantitative data indicated that the aim of MATE was well understood, and its usability and relevance were evaluated positively. In Phase 2, improvements to wording and format were suggested. MATE was subsequently amended prior to field testing. Phase 3 feedback indicated that MATE was highly effective for generating in-country dialogue and frank discussions about the future of midwifery education and practice. CONCLUSIONS: Using a co-design approach has ensured that MATE is culturally relevant, accessible and appropriate. This initial evaluation indicates that MATE can facilitate in-country dialogue and support the strengthening of midwifery education in accordance with WHO aims. Next steps are a fully evaluated trial of MATE in a selected partner country, where we will continue to work collaboratively to optimise engagement and ensure cultural appropriateness.

Dosage Optimization of Lamotrigine in Pregnancy: A Pharmacometric Approach Using Modeling and Simulation.

Lamotrigine is the most widely used anti-epileptic drug in pregnancy because of its low teratogenicity. However, there is an increased metabolism and clearance of lamotrigine in pregnancy contributing to suboptimal drug therapy and poor disease control, prompting the need for proactive dosage adjustments. The present study aimed to develop a pharmacometric model-based framework for recommending an optimal dosage regimen for lamotrigine in pregnancy. A systematic review was performed to obtain aggregate data from the literature on the clearance of lamotrigine in pregnancy. The data were incorporated into simulations using PUMAS software to estimate the plasma concentrations at the preconception stage and during the 3 trimesters of pregnancy. Simulated drug exposures for different doses were investigated to ascertain plasma concentrations similar to the preconception value and above the minimum effective concentration. The simulated mean steady-state trough plasma concentrations of lamotrigine were significantly decreased in pregnant women over the course of the 3 trimesters (3.17 ± 0.93 mg/L, 2.14 ± 0.86 mg/L, and 1.51 ± 0.65 mg/L, respectively), compared with non-pregnant women (4.31 ± 1.14 mg/L) (P < .001). The simulation studies revealed that doses of 150 mg, 175 mg, 225 mg, and 250 mg twice daily in the preconception stage and the 3 trimesters, respectively, achieve the target concentrations. Thus, the model-informed dosage regimen of lamotrigine proposed in this study shall be used to initiate appropriate dosing in pregnant women; however, the safety and efficacy of the drug must be assured through therapeutic drug monitoring in order to avoid therapeutic failure of lamotrigine in pregnancy.

Dehydration-Rehydration Studies on Polytypes of Chloride and Nitrate Layered Double Hydroxides of Nordstrandite and Bayerite: a Comparative Study.

In this work, we report for the first time, the dehydration-rehydration studies of nordstrandite-derived layered double hydroxides (LDHs) of Li and Al, n-[Li-Al-X] (X = Cl- and NO3 -) (n-nordstrandite derived). n-[Li-Al-NO3], an orthorhombic phase, dehydrated at 180 °C to a monoclinic phase. Refinement placed the NO3 - ions parallel to the hydroxide layers. The dehydration showed no change in basal spacing. The monoclinic n-[Li-Al-Cl] dehydrated at 160 °C with a 0.49 Å compression in basal spacing to an orthorhombic polytype. We compared our results with the published results of their bayerite counterparts b-[Li-Al-X] (b-bayerite derived) and observed that though n-[Li-Al-X] and b-[Li-Al-X] LDHs have similar structures, their dehydrated phases are structurally different. We also report the refinement of b-[Li-Al-Cl] (DH). Previous studies attribute the basal spacing values to the (i) degree of hydration and (ii) orientation of anions in the interlayer. We observe that basal spacing is a manifestation of the symmetry of the crystal. Dehydration of nitrate intercalated LDH, which proceeds from an orthorhombic symmetry to a monoclinic symmetry with no decrease in the interlayer spacing, is attributed to sliding of the hydroxyl layers in the ab-plane due to the increase in the ß value. This sliding stabilizes the interlayer through weak long-range electrostatic forces that mainly contribute to the stabilization of the layered structure at separations much larger than the effective radius of hydrogen bonds. Such stabilization would negate the need for the layers to compress, thus conserving the basal spacing in n-[Li-Al-NO3] (DH).

Forced association of SARS-CoV-2 proteins with the yeast proteome perturb vesicle trafficking.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the highly infectious coronavirus disease COVID-19. Extensive research has been performed in recent months to better understand how SARS-CoV-2 infects and manipulates its host to identify potential drug targets and support patient recovery from COVID-19. However, the function of many SARS-CoV-2 proteins remains uncharacterised. Here we used the Synthetic Physical Interactions (SPI) method to recruit SARS-CoV-2 proteins to most of the budding yeast proteome to identify conserved pathways which are affected by SARS-CoV-2 proteins. The set of yeast proteins that result in growth defects when associated with the viral proteins have homologous functions that overlap those identified in studies performed in mammalian cells. Specifically, we were able to show that recruiting the SARS-CoV-2 NSP1 protein to HOPS, a vesicle-docking complex, is sufficient to perturb membrane trafficking in yeast consistent with the hijacking of the endoplasmic-reticulum-Golgi intermediate compartment trafficking pathway during viral infection of mammalian cells. These data demonstrate that the yeast SPI method is a rapid way to identify potential functions of ectopic viral proteins.

Exploring the STEP-uP to practice: A survey of UK Lead Midwives for Education views of the STudent midwife Extended Practice Placement during the first wave of the COVID-19 pandemic.

OBJECTIVE: to assess the effect of implementation of the extended placement option available to midwifery students during the first wave of the COVID-19 pandemic. DESIGN: Online survey open from 2nd June 2020 to 15th July 2020. SETTING: United Kingdom. PARTICIPANTS: Lead Midwives for Education (LMEs). FINDINGS: A total of 38 of 55 LMEs responded (response rate 69%). The majority of Approved Education Institutions (AEIs) offered an extended placement to students, but with some variation in the choices offered, unrelated to geographical location or size of student cohort. AEIs appeared to provide the majority of decisional support for students. Many practice learning environments became unavailable, particularly community, gynaecology/medical wards and neonatal units. LMEs experienced both internal and external pressures to instigate rapid change. KEY CONCLUSIONS: The impact of COVID-19 on midwifery education is significant and will need continual scrutiny to minimise future detriment. The pressures of providing midwifery education throughout the early phase of COVID-19 were substantial, but it is important that we learn from the immediate changes made, value and pursue the changes that have been beneficial, and learn from those that were not. IMPLICATIONS FOR PRACTICE/RESEARCH: Student learning experiences have undergone significant change during the pandemic. It is essential to assess what effect the extended placement has had on student readiness for practice, their confidence, resilience, mental health, and attrition and retention. Educators transitioned to remote working, and rapidly assimilated new skills for online education; exploration of the impact of this is recommended.

Impaired adhesion of neutrophils expressing Slc44a2/HNA-3b to VWF protects against NETosis under venous shear rates.

Genome-wide association studies linked expression of the human neutrophil antigen 3b (HNA-3b) epitope on the Slc44a2 protein with a 30% decreased risk of venous thrombosis (VT) in humans. Slc44a2 is a ubiquitous transmembrane protein identified as a receptor for von Willebrand factor (VWF). To explain the link between Slc44a2 and VT, we wanted to determine how Slc44a2 expressing either HNA-3a or HNA-3b on neutrophils could modulate their adhesion and activation on VWF under flow. Transfected HEK293T cells or neutrophils homozygous for the HNA-3a- or HNA-3b-coding allele were purified from healthy donors and perfused in flow chambers coated with VWF at venous shear rates (100 s-1). HNA-3a expression was required for Slc44a2-mediated neutrophil adhesion to VWF at 100 s-1. This adhesion could occur independently of ß2 integrin and was enhanced when neutrophils were preactivated with lipopolysaccharide. Moreover, specific shear conditions with high neutrophil concentration could act as a "second hit," inducing the formation of neutrophil extracellular traps. Neutrophil mobilization was also measured by intravital microscopy in venules from SLC44A2-knockout and wild-type mice after histamine-induced endothelial degranulation. Mice lacking Slc44a2 showed a massive reduction in neutrophil recruitment in inflamed mesenteric venules. Our results show that Slc44a2/HNA-3a is important for the adhesion and activation of neutrophils in veins under inflammation and when submitted to specific shears. The fact that neutrophils expressing Slc44a2/HNA-3b have a different response on VWF in the conditions tested could thus explain the association between HNA-3b and a reduced risk for VT in humans.

Sustaining quality education and practice learning in a pandemic and beyond: 'I have never learnt as much in my life, as quickly, ever'.

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system. Findings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not 'just students'. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Natural Product-Derived Chiral Pyrrolidine-2,5-diones, Their Molecular Structures and Conversion to Pharmacologically Important Skeletons.

The versatility of the natural products (2S,3S)- and (2S,3R)-3-hydroxy-5-oxotetrahydrofuran-2,3-dicarboxylic acids (1 and 2), isolated in large amounts from tropical plant sources, has been demonstrated by the construction of 3-substituted and 3,4-disubstituted chiral pyrrolidine-2,5-diones. The absolute configurations of chiral pyrrolidine-2,5-diones have been ascertained using chiroptical spectroscopic methods and/or single-crystal XRD data. A combination of different reaction strategies delivering a diverse matrix of fused heterocyclic ring systems is presented. The pyrrolo[2,1-a]isoquinoline alkaloid (+)-crispine A possesses a wide range of pharmacological activities including antidepressant, antiplatelet, antileukemic, and anticancer activities. The analogues of indolizino[8,7-b]indole alkaloids (+)- and (-)-harmicine show strong antileishmanial, antinociceptive, PDE5-inhibitory, antimalarial, and antiviral activities. The bicyclic furo[2,3-b]pyrrolo skeleton is present in many natural products. Thus, the uniqueness of relatively cheap, naturally occurring chiral 2-hydroxycitric acid lactones as chirons has been demonstrated by the construction of some important molecular skeletons that are otherwise difficult to synthesize.

SLC44A2 deficient mice have a reduced response in stenosis but not in hypercoagulability driven venous thrombosis.

BACKGROUND: Genome wide association studies (GWAS) identified SLC44A2 as a novel susceptibility gene for venous thrombosis (VT) and previous work established that SLC44A2 contributed to clot formation upon vascular injury. OBJECTIVE: To further investigate the role of SLC44A2 in VT by utilizing SLC44A2 deficient mice (Slc44a2-/- ) in two representative disease models. METHODS: Mice were included in a hypercoagulability model driven by siRNA-mediated hepatic gene silencing of anticoagulants Serpinc1 (antithrombin) and Proc (protein C) and a flow restriction (stenosis) model induced by partial ligation of the inferior vena cava. RESULTS: In the hypercoagulability model, no effect in onset was observed in Slc44a2-/- animals; however, a drop in plasma fibrinogen and von Willebrand factor coinciding with an increase in blood neutrophils was recorded. In the neutrophil dependent stenosis model after 48 hours, Slc44a2-/- mice had significantly smaller thrombi both in length and weight with less platelet accumulation as a percentage of the total thrombus area. During the initiation of thrombosis at 6 hours post-stenosis, Slc44a2-/- mice also had smaller thrombi both in length and weight, with circulating platelets remaining elevated in Slc44a2-/- animals. Platelet activation and aggregation under both static- and venous and arterial shear conditions were normal for blood from Slc44a2-/- mice. CONCLUSIONS: These studies corroborate the original GWAS findings and establish a contributing role for SLC44A2 during the initiation of VT, with indications that this may be related to platelet-neutrophil interaction. The precise mechanism however remains elusive and warrants further investigation.

CATS: Cas9-assisted tag switching. A high-throughput method for exchanging genomic peptide tags in yeast.

BACKGROUND: The creation of arrays of yeast strains each encoding a different protein with constant tags is a powerful method for understanding how genes and their proteins control cell function. As genetic tools become more sophisticated there is a need to create custom libraries encoding proteins fused with specialised tags to query gene function. These include protein tags that enable a multitude of added functionality, such as conditional degradation, fluorescent labelling, relocalization or activation and also DNA and RNA tags that enable barcoding of genes or their mRNA products. Tools for making new libraries or modifying existing ones are becoming available, but are often limited by the number of strains they can be realistically applied to or by the need for a particular starting library. RESULTS: We present a new recombination-based method, CATS - Cas9-Assisted Tag Switching, that switches tags in any existing library of yeast strains. This method employs the reprogrammable RNA guided nuclease, Cas9, to both introduce endogenous double strand breaks into the genome as well as liberating a linear DNA template molecule from a plasmid. It exploits the relatively high efficiency of homologous recombination in budding yeast compared with non-homologous end joining. CONCLUSIONS: The method takes less than 2 weeks, is cost effective and can simultaneously introduce multiple genetic changes, thus providing a rapid, genome-wide approach to genetic modification.

Evidence that Ergosterol Biosynthesis Modulates Activity of the Pdr1 Transcription Factor in Candida glabrata.

A crucial limitation in antifungal chemotherapy is the limited number of antifungal drugs currently available. Azole drugs represent the most commonly used chemotherapeutic, and loss of efficacy of these drugs is a major risk factor in successful treatment of a variety of fungal diseases. Candida glabrata is a pathogenic yeast that is increasingly found associated with bloodstream infections, a finding likely contributed to by its proclivity to develop azole drug resistance. C. glabrata often acquires azole resistance via gain-of-function (GOF) mutations in the transcription factor Pdr1. These GOF forms of Pdr1 drive elevated expression of target genes, including the ATP-binding cassette transporter-encoding CDR1 locus. GOF alleles of PDR1 have been extensively studied, but little is known of how Pdr1 is normally regulated. Here we test the idea that reduction of ergosterol biosynthesis (as occurs in the presence of azole drugs) might trigger activation of Pdr1 function. Using two different means of genetically inhibiting ergosterol biosynthesis, we demonstrated that Pdr1 activity and target gene expression are elevated in the absence of azole drug. Blocks at different points in the ergosterol pathway lead to Pdr1 activation as well as to induction of other genes in this pathway. Delivery of the signal from the ergosterol pathway to Pdr1 involves the transcription factor Upc2A, an ERG gene regulator. We show that Upc2A binds directly to the PDR1 and CDR1 promoters. Our studies argue for a physiological link between ergosterol biosynthesis and Pdr1-dependent gene regulation that is not restricted to efflux of azole drugs.IMPORTANCE A likely contributor to the increased incidence of non-albicans candidemias involving Candida glabrata is the ease with which this yeast acquires azole resistance, in large part due to induction of the ATP-binding cassette transporter-encoding gene CDR1 Azole drugs lead to induction of Pdr1 transactivation, with a central model being that this factor binds these drugs directly. Here we provide evidence that Pdr1 is activated without azole drugs by the use of genetic means to inhibit expression of azole drug target-encoding gene ERG11 These acute reductions in Erg11 levels lead to elevated Pdr1 activity even though no drug is present. A key transcriptional regulator of the ERG pathway, Upc2A, is shown to directly bind to the PDR1 and CDR1 promoters. We interpret these data as support for the view that Pdr1 function is responsive to ergosterol biosynthesis and suggest that this connection reveals the normal physiological circuitry in which Pdr1 participates.

AtrR Is an Essential Determinant of Azole Resistance in Aspergillus fumigatus.

Aspergillosis associated with azole-resistant Aspergillus fumigatus has a mortality rate that can approach 90% in certain patient populations. The best-understood avenue for azole resistance involves changes in the cyp51A gene that encodes the target of azole drugs, lanosterol α-14 demethylase. The most common azole resistance allele currently described is a linked change corresponding to a change in the coding sequence of cyp51A and a duplication of a 34-bp region in the promoter leading to a tandem repeat (TR). Our previous studies identified a positively acting transcription factor called AtrR that binds to the promoter of cyp51A as well as that of an important membrane transporter protein gene called abcG1 In this work, we characterize two different mutant alleles of atrR, either an overproducing or an epitope-tagged form, causing constitutive activation of this factor. Using an epitope-tagged allele of atrR for chromatin immunoprecipitation coupled with high-throughput sequencing (ChIP-seq), the genomic binding sites for AtrR were determined. Close to 900 genes were found to have an AtrR response element (ATRE) in their promoter regions. Transcriptome evaluation by RNA sequencing (RNA-seq) indicated that both alleles led to elevated transcription of a subset of target genes. An electrophoretic mobility shift assay and DNase I protection mapping localized the ATREs in both the abcG1 and cyp51A promoters. The ATRE in cyp51A was located within the 34-bp repeat element. Virulence in a murine model was compromised when AtrR was either deleted or overproduced, indicating that the proper dosage of this factor is key for pathogenesis.IMPORTANCEAspergillus fumigatus is the major filamentous fungal pathogen in humans. Infections associated with A. fumigatus are often treated with azole drugs, but resistance to these antifungal agents is increasing. Mortality from aspergillosis associated with azole-resistant fungi is extremely high. Previous work has identified transcriptional control of the azole drug target-encoding gene cyp51A as an important contributor to resistance in A. fumigatus Here, we demonstrate that the transcription factor AtrR binds to a region in the cyp51A promoter that is associated with alleles of this gene conferring clinically important azole resistance. Using high-throughput genomic technologies, we also uncover a large suite of target genes controlled by AtrR. These data indicate that AtrR coordinately regulates many different processes involved in drug resistance, metabolism, and virulence. Our new understanding of AtrR function provides important new insight into the pathogenesis of A. fumigatus.

Role of micronutrients in congestive heart failure: A systematic review of randomized controlled trials.

OBJECTIVES: To assess the effect of micronutrients on health outcomes in patients with heart failure. MATERIALS AND METHODS: Only randomized controlled trials testing the effectiveness of different micronutrients either singly or combined versus placebo in heart failure patients were included. We conducted a search in different databases such as Medline from PubMed, Embase and Scopus from Elsevier, and Google Scholar. The keywords used in the search were "Heart Failure" and its cognates, "Micronutrient," "Minerals," and names of individual micronutrients. RESULTS: Out of 3288 titles and abstracts reviewed, only 11 trials comprising 529 individuals were found to be appropriate to be included in the final review. It was found that micronutrients, either single or combined, improved the health outcomes of heart failure patients by improving exercise tolerance, functional capacity, left ventricular function, flow-dependent dilation, and inflammatory milieu, thereby improving the quality of life of health failure patients. Certain micronutrients also normalized endothelial dysfunction. CONCLUSION: Overall, this systematic review found sufficient evidence to support a large-scale trial on micronutrient supplementation in patients with heart failure.

Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know.

Marijuana is the most widely used illicit drug, with approximately 200 million users worldwide. Once illegal throughout the United States, cannabis is now legal for medicinal purposes in several states and for recreational use in 3 states. The current wave of decriminalization may lead to more widespread use, and it is important that cardiologists be made aware of the potential for marijuana-associated adverse cardiovascular effects that may begin to occur in the population at a greater frequency. In this report, the investigators focus on the known cardiovascular, cerebrovascular, and peripheral effects of marijuana inhalation. Temporal associations between marijuana use and serious adverse events, including myocardial infarction, sudden cardiac death, cardiomyopathy, stroke, transient ischemic attack, and cannabis arteritis have been described. In conclusion, the potential for increased use of marijuana in the changing legal landscape suggests the need for the community to intensify research regarding the safety of marijuana use and for cardiologists to maintain an awareness of the potential for adverse effects.

Photodynamic therapy: an innovative approach to the treatment of keloid disease evaluated using subjective and objective non-invasive tools.

Optimal management for keloid disease (KD) is ill defined, with surgical excision resulting in recurrence rates over 50 %. Photodynamic therapy (PDT) uses light to activate a photosensitiser localised in diseased tissues. Two recent case studies and in vitro studies on keloid-derived fibroblasts indicate potential use of PDT in treating KD. Therefore, we hypothesized that there may be a role for PDT in the treatment of KD. Twenty KD patients were divided into three groups; existing keloid scar, post-surgical debulking and post-total surgical excision. Patients underwent three treatments of PDT at weekly intervals. Methyl aminolevulinate photosensitiser applied 3 h prior to PDT, administered at 37 J/cm(2). Non-invasive measures provided quantitative data for pliability, haemoglobin, melanin, collagen and flux. Pain and pruritus scores were measured and patients' were monitored for KD recurrence. All patients had reduced pain and pruritus scores. Haemoglobin flux (p = 0.032), collagen (p = 0.066) and haemoglobin levels (p = 0.060) decreased from week 1 to 3 in all except one patient where measurements were taken and pliability increased significantly (p = 0.001). Increases in pliability were significantly related to decreases in flux (p = 0.001). Only one patient with a keloid in a stress-prone anatomical location experienced recurrence of KD. All other patients had no recurrence at 9-month follow-up. Minimal side effects were reported. In conclusion, PDT reduces scar formation in KD evidenced by decreased blood flow, increased pliability, decreased collagen and haemoglobin levels. These findings indicate potential utility of PDT in the treatment of KD.