In vitro analysis of phosphorothioate modification of DNA reveals substrate recognition by a multiprotein complex

A wide variety of prokaryotes possess DNA modifications consisting of sequence-specific phosphorothioates (PT) inserted by members of a five-gene cluster. Recent genome mapping studies revealed two unusual features of PT modifications: short consensus sequences and partial modification of a specific genomic site in a population of bacteria. To better understand the mechanism of target selection of PT modifications that underlies these features, we characterized the substrate recognition of the PT-modifying enzymes termed DptC, D and E in a cell extract system from Salmonella. The results revealed that double-stranded oligodeoxynucleotides underwent de novo PT modification in vitro, with the same modification pattern as in vivo, i. e., GpsAAC/GpsTTC motif. Unexpectedly, in these in vitro analyses we observed no significant effect on PT modification by sequences flanking GAAC/GTTC motif, while PT also occurred in the GAAC/GTTC motif that could not be modified in vivo. Hemi-PT DNA also served as substrate of the PT-modifying enzymes, but not single-stranded DNA. The PT-modifying enzymes were then found to function as a large protein complex, with all of three subunits in tetrameric conformations. This study provided the first demonstration of in vitro DNA PT modification by PT-modifying enzymes that function as a large protein complex.National Natural Science Foundation (China) (Grant 31470183)National Natural Science Foundation (China) (Grant 31400029)National Natural Science Foundation (China) (Grant 31170085)National Natural Science Foundation (China) (Grant 30570400)National Natural Science Foundation (China) (Grant 31070058)China. Ministry of Science and Technology (Grant 2012CB721004)China. Ministry of Science and Technology (Grant 2009ZX09501-008)Shanghai Municipal Council of Science and Technology (Shanghai Pujiang Program Grant 12PJD021)China Scholarship CouncilNational Science Foundation (U.S.) (Grant CHE-1019990)National Institute of Environmental Health Sciences (Grant ES002109)Singapore. National Research Foundation (Singapore-MIT Alliance for Research and Technology

Identification and codon reading properties of 5-cyanomethyl uridine, a new modified nucleoside found in the anticodon wobble position of mutant haloarchaeal isoleucine tRNAs

Most archaea and bacteria use a modified C in the anticodon wobble position of isoleucine tRNA to base pair with A but not with G of the mRNA. This allows the tRNA to read the isoleucine codon AUA without also reading the methionine codon AUG. To understand why a modified C, and not U or modified U, is used to base pair with A, we mutated the C34 in the anticodon of Haloarcula marismortui isoleucine tRNA (tRNA2Ile) to U, expressed the mutant tRNA in Haloferax volcanii, and purified and analyzed the tRNA. Ribosome binding experiments show that although the wild-type tRNA2Ile binds exclusively to the isoleucine codon AUA, the mutant tRNA binds not only to AUA but also to AUU, another isoleucine codon, and to AUG, a methionine codon. The G34 to U mutant in the anticodon of another H. marismortui isoleucine tRNA species showed similar codon binding properties. Binding of the mutant tRNA to AUG could lead to misreading of the AUG codon and insertion of isoleucine in place of methionine. This result would explain why most archaea and bacteria do not normally use U or a modified U in the anticodon wobble position of isoleucine tRNA for reading the codon AUA. Biochemical and mass spectrometric analyses of the mutant tRNAs have led to the discovery of a new modified nucleoside, 5-cyanomethyl U in the anticodon wobble position of the mutant tRNAs. 5-Cyanomethyl U is present in total tRNAs from euryarchaea but not in crenarchaea, eubacteria, or eukaryotes.National Institutes of Health (U.S.) (GM17151)National Institutes of Health (U.S.) (GM22854)National Institutes of Health (U.S.) (ES017010)Singapore-MIT Alliance for Research and TechnologySingapore. National Research FoundationUnited States. Dept. of Energy (DE-FG36-08GO88055

tRNA-mediated codon-biased translation in mycobacterial hypoxic persistence

Microbial pathogens adapt to the stress of infection by regulating transcription, translation and protein modification. We report that changes in gene expression in hypoxia-induced non-replicating persistence in mycobacteria—which models tuberculous granulomas—are partly determined by a mechanism of tRNA reprogramming and codon-biased translation. Mycobacterium bovis BCG responded to each stage of hypoxia and aerobic resuscitation by uniquely reprogramming 40 modified ribonucleosides in tRNA, which correlate with selective translation of mRNAs from families of codon-biased persistence genes. For example, early hypoxia increases wobble cmo[superscript 5]U in tRNA[superscript Thr(UGU)], which parallels translation of transcripts enriched in its cognate codon, ACG, including the DosR master regulator of hypoxic bacteriostasis. Codon re-engineering of dosR exaggerates hypoxia-induced changes in codon-biased DosR translation, with altered dosR expression revealing unanticipated effects on bacterial survival during hypoxia. These results reveal a coordinated system of tRNA modifications and translation of codon-biased transcripts that enhance expression of stress response proteins in mycobacteria.Singapore-MIT Alliance for Research and Technology (SMART)National Institute of Environmental Health Sciences (grants ES017010 and ES002109)National Science Foundation (U.S.) (grant CHE-1308839)Singapore-MIT Alliance for Research and Technology (SMART) (SMA3 Graduate Fellowship

Diastereoselective Synthesis of Pyranoquinolines on Zirconium-Containing UiO-66 Metal-Organic Frameworks

[EN] The Zr terephthalate MOFs UiO-66 and UiO-66-NH2 have been found to be highly diastereoselective catalysts for the synthesis of a pyrano[3,2-c]quinoline through an inverse electron -demand aza-Diels-Alder [4+2] cycloaddition of an aryl Qmine (formed in situ from aniline and benzaldehyde) and 3,4-dihydro-2H-pyran in one pot, affording the corresponding trans isomer in diastereomeric excesses of 90-95 %. The solids are stable under the reaction conditions and can be reused at least three times without significant loss of activity or diastereoselectivity.Financial support from the Generalitat Valenciana (projects Consolider-Ingenio MULTICAT and AICO/2015/065), the Spanish Ministry of Economy and Competitiveness (MINECO) (program Severn Ochoa SEV20120267), and the Spanish Ministry of Science and Innovation (MICINN) (project MAT2014-52085-C2-1-P) is gratefully acknowledged. V. L. R. thanks the Fundacion "La Caixa" for a "La Caixa-Severo Ochoa" Ph. D. Scholarship. This project received funding from the European Union's Horizon 2020 Tesearch and Innovation Programme under the Marie Skolodowska Curie grant agreement number 641887.López-Rechac, V.; García Cirujano, F.; Corma Canós, A.; Llabrés I Xamena, FX. (2016). Diastereoselective Synthesis of Pyranoquinolines on Zirconium-Containing UiO-66 Metal-Organic Frameworks. European Journal of Inorganic Chemistry. 27:4512-4516. https://doi.org/10.1002/ejic.201600372S4512451627Li, B., Wang, H., & Chen, B. (2014). Microporous Metal-Organic Frameworks for Gas Separation. Chemistry - An Asian Journal, 9(6), 1474-1498. doi:10.1002/asia.201400031Li, J.-R., Sculley, J., & Zhou, H.-C. (2011). Metal–Organic Frameworks for Separations. Chemical Reviews, 112(2), 869-932. doi:10.1021/cr200190sRodenas, T., Luz, I., Prieto, G., Seoane, B., Miro, H., Corma, A., … Gascon, J. (2014). Metal–organic framework nanosheets in polymer composite materials for gas separation. Nature Materials, 14(1), 48-55. doi:10.1038/nmat4113Corma, A., García, H., & Llabrés i Xamena, F. X. (2010). Engineering Metal Organic Frameworks for Heterogeneous Catalysis. Chemical Reviews, 110(8), 4606-4655. doi:10.1021/cr9003924Farrusseng, D., Aguado, S., & Pinel, C. (2009). Metal-Organic Frameworks: Opportunities for Catalysis. Angewandte Chemie International Edition, 48(41), 7502-7513. doi:10.1002/anie.200806063Farrusseng, D., Aguado, S., & Pinel, C. (2009). Metall-organische Gerüste für die Katalyse. Angewandte Chemie, 121(41), 7638-7649. doi:10.1002/ange.200806063Llabres i Xamena, F., & Gascon, J. (Eds.). (2013). Metal Organic Frameworks as Heterogeneous Catalysts. Catalysis Series. doi:10.1039/9781849737586Gascon, J., Corma, A., Kapteijn, F., & Llabrés i Xamena, F. X. (2013). Metal Organic Framework Catalysis: Quo vadis? ACS Catalysis, 4(2), 361-378. doi:10.1021/cs400959kYamada, N., Kadowaki, S., Takahashi, K., & Umezu, K. (1992). MY-1250, a major metabolite of the anti-allergic drug repirinast, induces phosphorylation of a 78-kDa protein in rat mast cells. Biochemical Pharmacology, 44(6), 1211-1213. doi:10.1016/0006-2952(92)90387-xFaber, K., StÚckler, H., & Kappe, T. (1984). Non-steroidal antiinflammatory agents.1. Synthesis of 4-hydroxy-2-oxo-1,2-dihydroquinolin-3-yl alkanoic acids by the wittig reaction of quinisatines. Journal of Heterocyclic Chemistry, 21(4), 1177-1181. doi:10.1002/jhet.5570210450Weirich, J., & Antoni, H. (1990). Differential Analysis of the Frequency-Dependent Effects of Class 1 Antiarrhythmic Drugs According to Periodical Ligand Binding. Journal of Cardiovascular Pharmacology, 15(6), 998-1009. doi:10.1097/00005344-199006000-00019Jacquemond-Collet, I., Benoit-Vical, F., Valentin, A., Stanislas, E., Mallié, M., & Fourasté, I. (2002). Antiplasmodial and Cytotoxic Activity of Galipinine and other Tetrahydroquinolines from Galipea officinalis. Planta Medica, 68(1), 68-69. doi:10.1055/s-2002-19869Wallace, O. B., Lauwers, K. S., Jones, S. A., & Dodge, J. A. (2003). Tetrahydroquinoline-Based selective estrogen receptor modulators (SERMs). Bioorganic & Medicinal Chemistry Letters, 13(11), 1907-1910. doi:10.1016/s0960-894x(03)00306-8Dorey, G., Lockhart, B., Lestage, P., & Casara, P. (2000). New quinolinic derivatives as centrally active antioxidants. Bioorganic & Medicinal Chemistry Letters, 10(9), 935-939. doi:10.1016/s0960-894x(00)00122-0Preface. (1996). Zeolites, 17(1-2), 1-2. doi:10.1016/s0144-2449(96)80002-9Ramesh, M., Mohan, P. S., & Shanmugam, P. (1984). A convenient synthesis of flindersine, atanine and their analogues. Tetrahedron, 40(20), 4041-4049. doi:10.1016/0040-4020(84)85084-xCirujano, F. G., Leyva-Pérez, A., Corma, A., & Llabrés i Xamena, F. X. (2013). MOFs as Multifunctional Catalysts: Synthesis of Secondary Arylamines, Quinolines, Pyrroles, and Arylpyrrolidines over Bifunctional MIL-101. ChemCatChem, 5(2), 538-549. doi:10.1002/cctc.201200878Povarov, L. S. (1967). αβ-UNSATURATED ETHERS AND THEIR ANALOGUES IN REACTIONS OF DIENE SYNTHESIS. Russian Chemical Reviews, 36(9), 656-670. doi:10.1070/rc1967v036n09abeh001680Nagarapu, L., Bantu, R., & Puligoundla, R. G. (2011). Tin(II)chloride catalyzed synthesis of pyranoquinolines, phenanthridinone and phenanthridine derivatives. European Journal of Chemistry, 2(2), 260-265. doi:10.5155/eurjchem.2.2.260-265.263Mahajan, D., Ganai, B. A., Sharma, R. L., & Kapoor, K. K. (2006). Antimony chloride doped on hydroxyapetite catalyzed stereoselective one-pot synthesis of pyrano[3,2-c]quinolines. Tetrahedron Letters, 47(45), 7919-7921. doi:10.1016/j.tetlet.2006.09.007Abdollahi-Alibeik, M., & Pouriayevali, M. (2011). 12-Tungstophosphoric acid supported on nano sized MCM-41 as an efficient and reusable solid acid catalyst for the three-component imino Diels–Alder reaction. Reaction Kinetics, Mechanisms and Catalysis, 104(1), 235-248. doi:10.1007/s11144-011-0345-9Kamble, V. T., Davane, B. S., Chavan, S. A., Muley, D. B., & Atkore, S. T. (2010). Imino Diels–Alder reactions: One-pot synthesis of tetrahydroquinolines. Chinese Chemical Letters, 21(3), 265-268. doi:10.1016/j.cclet.2009.11.016Yu, Y., Zhou, J., Yao, Z., Xu, F., & Shen, Q. (2010). Stereoselective synthesis of pyrano[3,2-c]- and furano[3,2-c]quinolines: Gadolinium chloride catalyzed one-pot aza-Diels-Alder reactions. Heteroatom Chemistry, 21(5), 351-354. doi:10.1002/hc.20612Khan, A. T., Das, D. K., & Khan, M. M. (2011). Ferric sulfate [Fe2(SO4)3·xH2O]: an efficient heterogeneous catalyst for the synthesis of tetrahydroquinoline derivatives using Povarov reaction. Tetrahedron Letters, 52(35), 4539-4542. doi:10.1016/j.tetlet.2011.06.080Jeong, K. S., Go, Y. B., Shin, S. M., Lee, S. J., Kim, J., Yaghi, O. M., & Jeong, N. (2011). Asymmetric catalytic reactions by NbO-type chiral metal–organic frameworks. Chemical Science, 2(5), 877. doi:10.1039/c0sc00582gVermoortele, F., Ameloot, R., Alaerts, L., Matthessen, R., Carlier, B., Fernandez, E. V. R., … De Vos, D. E. (2012). Tuning the catalytic performance of metal–organic frameworks in fine chemistry by active site engineering. Journal of Materials Chemistry, 22(20), 10313. doi:10.1039/c2jm16030gGole, B., Bar, A. K., Mallick, A., Banerjee, R., & Mukherjee, P. S. (2013). An electron rich porous extended framework as a heterogeneous catalyst for Diels–Alder reactions. Chemical Communications, 49(67), 7439. doi:10.1039/c3cc43681kGrigoropoulos, A., Whitehead, G. F. S., Perret, N., Katsoulidis, A. P., Chadwick, F. M., Davies, R. P., … Rosseinsky, M. J. (2016). Encapsulation of an organometallic cationic catalyst by direct exchange into an anionic MOF. Chemical Science, 7(3), 2037-2050. doi:10.1039/c5sc03494aLiu, Y., Mo, K., & Cui, Y. (2013). Porous and Robust Lanthanide Metal-Organoboron Frameworks as Water Tolerant Lewis Acid Catalysts. Inorganic Chemistry, 52(18), 10286-10291. doi:10.1021/ic400598xFeng, D., Gu, Z.-Y., Chen, Y.-P., Park, J., Wei, Z., Sun, Y., … Zhou, H.-C. (2014). A Highly Stable Porphyrinic Zirconium Metal–Organic Framework with shp-a Topology. Journal of the American Chemical Society, 136(51), 17714-17717. doi:10.1021/ja510525sCavka, J. H., Jakobsen, S., Olsbye, U., Guillou, N., Lamberti, C., Bordiga, S., & Lillerud, K. P. (2008). A New Zirconium Inorganic Building Brick Forming Metal Organic Frameworks with Exceptional Stability. Journal of the American Chemical Society, 130(42), 13850-13851. doi:10.1021/ja8057953Valenzano, L., Civalleri, B., Chavan, S., Bordiga, S., Nilsen, M. H., Jakobsen, S., … Lamberti, C. (2011). Disclosing the Complex Structure of UiO-66 Metal Organic Framework: A Synergic Combination of Experiment and Theory. Chemistry of Materials, 23(7), 1700-1718. doi:10.1021/cm1022882Cirujano, F. G., Corma, A., & Llabrés i Xamena, F. X. (2015). Zirconium-containing metal organic frameworks as solid acid catalysts for the esterification of free fatty acids: Synthesis of biodiesel and other compounds of interest. Catalysis Today, 257, 213-220. doi:10.1016/j.cattod.2014.08.015Cirujano, F. G., Corma, A., & Llabrés i Xamena, F. X. (2015). Conversion of levulinic acid into chemicals: Synthesis of biomass derived levulinate esters over Zr-containing MOFs. Chemical Engineering Science, 124, 52-60. doi:10.1016/j.ces.2014.09.047Vermoortele, F., Bueken, B., Le Bars, G., Van de Voorde, B., Vandichel, M., Houthoofd, K., … De Vos, D. E. (2013). Synthesis Modulation as a Tool To Increase the Catalytic Activity of Metal–Organic Frameworks: The Unique Case of UiO-66(Zr). Journal of the American Chemical Society, 135(31), 11465-11468. doi:10.1021/ja405078uVermoortele, F., Vandichel, M., Van de Voorde, B., Ameloot, R., Waroquier, M., Van Speybroeck, V., & De Vos, D. E. (2012). Electronic Effects of Linker Substitution on Lewis Acid Catalysis with Metal-Organic Frameworks. Angewandte Chemie International Edition, 51(20), 4887-4890. doi:10.1002/anie.201108565Vermoortele, F., Vandichel, M., Van de Voorde, B., Ameloot, R., Waroquier, M., Van Speybroeck, V., & De Vos, D. E. (2012). Electronic Effects of Linker Substitution on Lewis Acid Catalysis with Metal-Organic Frameworks. Angewandte Chemie, 124(20), 4971-4974. doi:10.1002/ange.201108565Da Silva-Filho, L., da Silva, B., & Martins, L. (2012). Niobium Pentachloride Catalyzed Multicomponent Povarov Reaction. Synlett, 23(13), 1973-1977. doi:10.1055/s-0032-1316587Zhou, Z., Xu, F., Han, X., Zhou, J., & Shen, Q. (2007). Stereoselective Synthesis of Pyrano[3,2-c]- and Furano[3,2-c]quinolines: Samarium Diiodide-Catalyzed One-Pot Aza-Diels–Alder Reactions. European Journal of Organic Chemistry, 2007(31), 5265-5269. doi:10.1002/ejoc.200700288Babu, G., & Perumal, P. T. (1998). Convenient synthesis of pyrano[3,2-c]quinolines and indeno[2,1-c] quinolines by imino Diels-Alder reactions. Tetrahedron Letters, 39(20), 3225-3228. doi:10.1016/s0040-4039(98)00397-9Yadav, J., Subba Reddy, B., Madhuri, C. R., & Sabitha, G. (2004). LiBF4-Catalyzed Imino-Diels-Alder Reaction: A Facile Synthesis of Pyrano- and Furoquinolines. Synthesis, 2001(07). doi:10.1055/s-2001-14904Semwal, A., & Nayak, S. K. (2006). Copper(II) Bromide–Catalyzed Imino Diels–Alder Reaction: Synthesis of Pyrano[3,2‐c]‐ and Furo [3,2‐c]tetrahydroquinolines. Synthetic Communications, 36(2), 227-236. doi:10.1080/00397910500334595Domingo, L. R., Aurell, M. J., Sáez, J. A., & Mekelleche, S. M. (2014). Understanding the mechanism of the Povarov reaction. A DFT study. RSC Advances, 4(48), 25268. doi:10.1039/c4ra02916jLucchini, V., Prato, M., Scorrano, G., Stivanello, M., & Valle, G. (1992). Acid-catalysed addition of N-aryl imines to dihydrofuran. Postulated dependence of the reaction mechanism on the relative face of approach of reactants. Journal of the Chemical Society, Perkin Transactions 2, (2), 259. doi:10.1039/p29920000259Xu, X., Rummelt, S. M., Morel, F. L., Ranocchiari, M., & van Bokhoven, J. A. (2014). Selective Catalytic Behavior of a Phosphine-Tagged Metal-Organic Framework Organocatalyst. Chemistry - A European Journal, 20(47), 15467-15472. doi:10.1002/chem.201404498Schoenecker, P. M., Carson, C. G., Jasuja, H., Flemming, C. J. J., & Walton, K. S. (2012). Effect of Water Adsorption on Retention of Structure and Surface Area of Metal–Organic Frameworks. Industrial & Engineering Chemistry Research, 51(18), 6513-6519. doi:10.1021/ie202325pKandiah, M., Nilsen, M. H., Usseglio, S., Jakobsen, S., Olsbye, U., Tilset, M., … Lillerud, K. P. (2010). Synthesis and Stability of Tagged UiO-66 Zr-MOFs. Chemistry of Materials, 22(24), 6632-6640. doi:10.1021/cm102601

A multidimensional platform for the purification of non-coding RNA species

A renewed interest in non-coding RNA (ncRNA) has led to the discovery of novel RNA species and post-transcriptional ribonucleoside modifications, and an emerging appreciation for the role of ncRNA in RNA epigenetics. Although much can be learned by amplification-based analysis of ncRNA sequence and quantity, there is a significant need for direct analysis of RNA, which has led to numerous methods for purification of specific ncRNA molecules. However, no single method allows purification of the full range of cellular ncRNA species. To this end, we developed a multidimensional chromatographic platform to resolve, isolate and quantify all canonical ncRNAs in a single sample of cells or tissue, as well as novel ncRNA species. The applicability of the platform is demonstrated in analyses of ncRNA from bacteria, human cells and plasmodium-infected reticulocytes, as well as a viral RNA genome. Among the many potential applications of this platform are a system-level analysis of the dozens of modified ribonucleosides in ncRNA, characterization of novel long ncRNA species, enhanced detection of rare transcript variants and analysis of viral genomes.Singapore-MIT Alliance for Research and TechnologyNational Institute of Environmental Health Sciences (ES017010)National Institute of Environmental Health Sciences (ES002109

Economic evaluation of shortened, bedaquiline-containing treatment regimens for rifampicin-resistant tuberculosis (STREAM stage 2) : a within-trial analysis of a randomised controlled trial

Background: The STREAM stage 2 trial assessed two bedaquiline-containing regimens for rifampicin-resistant tuberculosis: a 9-month all-oral regimen and a 6-month regimen containing an injectable drug for the first 2 months. We did a within-trial economic evaluation of these regimens. Methods: STREAM stage 2 was an international, phase 3, non-inferiority randomised trial in which participants with rifampicin-resistant tuberculosis were randomly assigned (1:2:2:2) to the 2011 WHO regimen (terminated early), a 9-month injectable-containing regimen (control regimen), a 9-month all-oral regimen with bedaquiline (oral regimen), or a 6-month regimen with bedaquiline and an injectable for the first 2 months (6-month regimen). We prospectively collected direct and indirect costs and health-related quality of life data from trial participants until week 76 of follow-up. Cost-effectiveness of the oral and 6-month regimens versus control was estimated in four countries (oral regimen) and two countries (6-month regimen), using health-related quality of life for cost-utility analysis and trial efficacy for cost-effectiveness analysis. This trial is registered with ISRCTN, ISRCTN18148631. Findings: 300 participants were included in the economic analyses (Ethiopia, 61; India, 142; Moldova, 51; Uganda, 46). In the cost-utility analysis, the oral regimen was not cost-effective in Ethiopia, India, Moldova, and Uganda from either a provider or societal perspective. In Moldova, the oral regimen was dominant from a societal perspective. In the cost-effectiveness analysis, the oral regimen was likely to be cost-effective from a provider perspective at willingness-to-pay thresholds per additional favourable outcome of more than US$4500 in Ethiopia,$1900 in India, $3950 in Moldova, and$7900 in Uganda, and from a societal perspective at thresholds of more than $15 900 in Ethiopia,$3150 in India, and $4350 in Uganda, while in Moldova the oral regimen was dominant. In Ethiopia and India, the 6-month regimen would cost tuberculosis programmes and participants less than the control regimen and was highly likely to be cost-effective in both cost-utility analysis and cost-effectiveness analysis. Reducing the bedaquiline price from$1·81 to $1·00 per tablet made the oral regimen cost-effective in the provider-perspective cost-utility analysis in India and Moldova and dominate over the control regimen in the provider-perspective cost-effectiveness analysis in India. Interpretation: At current costs, the oral bedaquiline-containing regimen for rifampicin-resistant tuberculosis is unlikely to be cost-effective in many low-income and middle-income countries. The 6-month regimen represents a cost-effective alternative if injectable use for 2 months is acceptable. Funding: USAID and Janssen Research & Development

Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all-cause mortality in the 14 171 participants in the intention-to-treat population. The median age was 73 years, and the mean CHADS(2) score was 3.5. Over 1.9 years of median follow-up, 1214 (8.6%) patients died. Kaplan-Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all-cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33-1.70, P= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

Global burden of chronic respiratory diseases and risk factors, 1990–2019: an update from the Global Burden of Disease Study 2019

Background: Updated data on chronic respiratory diseases (CRDs) are vital in their prevention, control, and treatment in the path to achieving the third UN Sustainable Development Goals (SDGs), a one-third reduction in premature mortality from non-communicable diseases by 2030. We provided global, regional, and national estimates of the burden of CRDs and their attributable risks from 1990 to 2019. Methods: Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated mortality, years lived with disability, years of life lost, disability-adjusted life years (DALYs), prevalence, and incidence of CRDs, i.e. chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis, interstitial lung disease and pulmonary sarcoidosis, and other CRDs, from 1990 to 2019 by sex, age, region, and Socio-demographic Index (SDI) in 204 countries and territories. Deaths and DALYs from CRDs attributable to each risk factor were estimated according to relative risks, risk exposure, and the theoretical minimum risk exposure level input. Findings: In 2019, CRDs were the third leading cause of death responsible for 4.0 million deaths (95% uncertainty interval 3.6–4.3) with a prevalence of 454.6 million cases (417.4–499.1) globally. While the total deaths and prevalence of CRDs have increased by 28.5% and 39.8%, the age-standardised rates have dropped by 41.7% and 16.9% from 1990 to 2019, respectively. COPD, with 212.3 million (200.4–225.1) prevalent cases, was the primary cause of deaths from CRDs, accounting for 3.3 million (2.9–3.6) deaths. With 262.4 million (224.1–309.5) prevalent cases, asthma had the highest prevalence among CRDs. The age-standardised rates of all burden measures of COPD, asthma, and pneumoconiosis have reduced globally from 1990 to 2019. Nevertheless, the age-standardised rates of incidence and prevalence of interstitial lung disease and pulmonary sarcoidosis have increased throughout this period. Low- and low-middle SDI countries had the highest age-standardised death and DALYs rates while the high SDI quintile had the highest prevalence rate of CRDs. The highest deaths and DALYs from CRDs were attributed to smoking globally, followed by air pollution and occupational risks. Non-optimal temperature and high body-mass index were additional risk factors for COPD and asthma, respectively. Interpretation: Albeit the age-standardised prevalence, death, and DALYs rates of CRDs have decreased, they still cause a substantial burden and deaths worldwide. The high death and DALYs rates in low and low-middle SDI countries highlights the urgent need for improved preventive, diagnostic, and therapeutic measures. Global strategies for tobacco control, enhancing air quality, reducing occupational hazards, and fostering clean cooking fuels are crucial steps in reducing the burden of CRDs, especially in low- and lower-middle income countries