Authors’ Reply to Denning: Comment on: “Global Consumption Trend of Antifungal Agents in Humans From 2008 to 2018: Data From 65 Middle- and High-Income Countries”

thank you for the opportunity to respond to the comments raised in Prof. Denning’s letter. We also thank Prof. Denning for taking an interest in our paper and speculating on possibilities for an increase in itraconazole consumption, particularly in middle-income countries. In his letter [1], Prof. Denning postulated reasons for the increased consumption of itraconazole, preceding its listing in the World Health Organization (WHO)’s Essential Medicine List (EML) in 2017. We agree that several factors, including the inclusion of itraconazole into the chronic pulmonary aspergillosis (CPA) guideline in early 2016, the high prevalence of recurrent vulvovaginal candidiasis, and the increased awareness about histoplasmosis in patients with acquired immunodeficiency syndrome in African countries, could influence the increase in overall consumption of itraconazole in middle-income countries

Global Consumption Trend of Antifungal Agents in Humans From 2008 to 2018: Data From 65 Middle- and High-Income Countries

Background: Understanding the trend of global antifungal agent consumption could assist with identification of global healthcare policy inadequacies and promote accessibility and availability of antifungal agents. Methods: Using pharmaceutical sales data from the IQVIA-multinational integrated data analysis system database, we assessed use of systemic antifungal agents in humans in 27 middle- and 38 high-income countries from 2008 through 2018. Results: Consumption of systemic antifungal agents increased from 0.50 (in 2008) to 0.92 defined daily dose (DDD)/1000 inhabitants/day (in 2018), with a compound annual growth rate of 6.2%. High-income countries remain major consumers of antifungal agents with large variance in quantities consumed, with a gradual decline in consumption in recent years. Consumption in middle-income countries increased. Itraconazole (0.32 DDD/1000 inhabitants/day), terbinafine (0.30 DDD/1000 inhabitants/day), and fluconazole (0.23 DDD/1000 inhabitants/day) were the most commonly used antifungal agents in middle- and high-income countries in 2018. Following incorporation into the World Health Organization Essential Medicines List, itraconazole consumption in middle-income countries surged. Consumption of ketoconazole slowly declined, with 5.04% annual decrease, probably due to labelling changes in 2013 to reflect hepatotoxicity concerns. The use of polyenes (0.004 DDD/1000 inhabitants/day) and echinocandins (0.003 DDD/1000 inhabitants/day) were lowest among all the antifungal drug classes. Conclusion: Global consumption of triazoles and terbinafine has gradually increased in middle- and high-income countries. Life-saving antifungal agents, including echinocandins and polyenes, are available only parenterally and may be underutilized, mainly in middle-income countries. Future research on country-specific epidemiology is warranted to guide health policy coordination to ensure equitable access to appropriate use of antifungal agents

Effects of over-expressing resistin on glucose and lipid metabolism in mice*

Resistin, a newly discovered peptide hormone mainly secreted by adipose tissues, is present at high levels in serum of obese mice and may be a potential link between obesity and insulin resistance in rodents. However, some studies of rat and mouse models have associated insulin resistance and obesity with decreased resistin expression. In humans, no relationship between resistin level and insulin resistance or adiposity was observed. This suggests that additional studies are necessary to determine the specific role of resistin in the regulation of energy metabolism and adipogenesis. In the present study, we investigated the effect of resistin in vivo on glucose and lipid metabolism by over-expressing resistin in mice by intramuscular injection of a recombinant eukaryotic expression vector pcDNA3.1-Retn encoding porcine resistin gene. After injection, serum resistin and serum glucose (GLU) levels were significantly increased in the pcDNA3.1-Retn-treated mice; there was an obvious difference in total cholesterol (TC) level between the experiment and the control groups on Day 30. In pcDNA3.1-Retn-treated mice, both free fatty acid (FFA) and high density lipoprotein (HDL) cholesterol levels were markedly lower than those of control, whereas HDL cholesterol and triglyceride (TG) levels did not differ between the two groups. Furthermore, lipase activity was expressly lower on Day 20. Our data suggest that resistin over-expressed in mice might be responsible for insulin resistance and parameters related to glucose and lipid metabolism were changed accordingly

Morphologic observation and classification criteria of atretic follicles in guinea pigs*

There is a lack of appropriate classification criteria for the determination of atretic follicles in guinea pigs. In the present study, new criteria were established based on the latest morphologic criteria for cell death proposed by the Nomenclature Committee on Cell Death (NCCD) in 2009. Ovaries of guinea pigs were sampled on different stages of estrous cycle, and the morphologic observations of atretic follicles were investigated in serial sections. The results showed that the process of follicular atresia could be classified into four continuous stages: (1) the granulosa layer became loose, and some apoptotic bodies began to appear; (2) the granulosa cells were massively eliminated; (3) the theca interna cells differentiated; and (4) the residual follicular cells degenerated. In addition, the examination revealed that these morphologic criteria were accurate and feasible. In conclusion, this study provides new criteria for the classification of atretic follicles in guinea pigs, and this knowledge can inform future research in the area