Adult congenital heart disease training in Europe: current status, disparities and potential solutions.

OBJECTIVES: This study aimed to determine the status of training of adult congenital heart disease (ACHD) cardiologists in Europe. METHODS: A questionnaire was sent to ACHD cardiologists from 34 European countries. RESULTS: Representatives from 31 of 34 countries (91%) responded. ACHD cardiology was recognised by the respective ministry of Health in two countries (7%) as a subspecialty. Two countries (7%) have formally recognised ACHD training programmes, 15 (48%) have informal (neither accredited nor certified) training and 14 (45%) have very limited or no programme. Twenty-five countries (81%) described training ACHD doctors 'on the job'. The median number of ACHD centres per country was 4 (range 0-28), median number of ACHD surgical centres was 3 (0-26) and the median number of ACHD training centres was 2 (range 0-28). An established exit examination in ACHD was conducted in only one country (3%) and formal certification provided by two countries (7%). ACHD cardiologist number versus gross domestic product Pearson correlation coefficient=0.789 (p<0.001). CONCLUSION: Formal or accredited training in ACHD is rare among European countries. Many countries have very limited or no training and resort to 'train people on the job'. Few countries provide either an exit examination or certification. Efforts to harmonise training and establish standards in exit examination and certification may improve training and consequently promote the alignment of high-quality patient care.

Artemisia santonicum L. and Artemisia lerchiana Web. Essential Oils and Exudates as Sources of Compounds with Pesticidal Action.

The application of natural products for pest control is important in modern farming. In the present study, Artemisia santonicum L. and Artemisia lerchiana Weber essential oil and exudate profiles were determined, and their potential as inhibitors of seed germination, acetylcholinesterase, and phytopathogenic mycelium growth were evaluated. Essential oils (EO) were obtained via hydrodistillation and exudates (AE) by washing aerial parts of the species with acetone. EO and AE's composition was identified using GC/MS. Eucalyptol (1,8-cineole) and camphor were found to be the main components of A. lerchiana EO, while ß-pinene, trans-pinocarveol, α-pinene, α-terpineol, and spathulenol were established as major compounds of A. santonicum EO. Strong inhibition on Lolium perenne seed germination was found at 2 µL/mL and 5 mg/mL using aqueous solutions of EO and AE, respectively. An inhibitory effect on acetylcholinesterase was established, with an IC50 value of 64.42 and 14.60 µg/mL for EO and 0.961, >1 mg/mL for the AE of A. lerchiana and A. santonicum, respectively. The low inhibition on the mycelium growth of studied phytopathogenic fungi was established by applying 2 µL of EO and 15 µL of 100 mg/mL of AE, with the exception of A. lerchiana AE against Botrytis cinerea. These results show that the studied EO and AE exhibited strong phytotoxic and AChE inhibitory activities, providing new data for these species.

Design, Synthesis, In Silico Studies and In Vitro Evaluation of New Indole- and/or Donepezil-like Hybrids as Multitarget-Directed Agents for Alzheimer's Disease.

Alzheimer's disease (AD) is considered a complex neurodegenerative condition which warrants the development of multitargeted drugs to tackle the key pathogenetic mechanisms of the disease. In this study, two novel series of melatonin- and donepezil-based hybrid molecules with hydrazone (3a-r) or sulfonyl hydrazone (5a-l) fragments were designed, synthesized, and evaluated as multifunctional ligands against AD-related neurodegenerative mechanisms. Two lead compounds (3c and 3d) exhibited a well-balanced multifunctional profile, demonstrating intriguing acetylcholinesterase (AChE) inhibition, promising antioxidant activity assessed by DPPH, ABTS, and FRAP methods, as well as the inhibition of lipid peroxidation in the linoleic acid system. Compound 3n, possessing two indole scaffolds, showed the highest activity against butyrylcholinesterase (BChE) and a high selectivity index (SI = 47.34), as well as a pronounced protective effect in H2O2-induced oxidative stress in SH-SY5Y cells. Moreover, compounds 3c, 3d, and 3n showed low neurotoxicity against malignant neuroblastoma cell lines of human (SH-SY5Y) and murine (Neuro-2a) origin, as well as normal murine fibroblast cells (CCL-1) that indicate the in vitro biocompatibility of the experimental compounds. Furthermore, compounds 3c, 3d, and 3n were capable of penetrating the blood-brain barrier (BBB) in the experimental PAMPA-BBB study. The molecular docking showed that compound 3c could act as a ligand to both MT1 and MT2 receptors, as well as to AchE and BchE enzymes. Taken together, those results outline compounds 3c, 3d, and 3n as promising prototypes in the search of innovative compounds for the treatment of AD-associated neurodegeneration with oxidative stress. This study demonstrates that hydrazone derivatives with melatonin and donepezil are appropriate for further development of new AChE/BChE inhibitory agents.

Virtual Screening and Hit Selection of Natural Compounds as Acetylcholinesterase Inhibitors.

Acetylcholinesterase (AChE) is one of the classical targets in the treatment of Alzheimer's disease (AD). Inhibition of AChE slows down the hydrolysis of acetycholine and increases choline levels, improving the cognitive function. The achieved success of plant-based natural drugs acting as AChE inhibitors, such as galantamine (GAL) from Galanthus genus and huperzine A from Huperzia serrate (approved drug in China), in the treatment of AD, and the fact that natural compounds (NCs) are considered as safer and less toxic compared to synthetic drugs, led us to screen the available NCs (almost 150,000) in the ZINC12 database for AChE inhibitory activity. The compounds were screened virtually by molecular docking, filtered for suitable ADME properties, and 32 ligands from 23 structural groups were selected. The stability of the complexes was estimated via 1 µs molecular dynamics simulation. Ten compounds formed stable complexes with the enzyme and had a vendor and a reasonable price per mg. They were tested for AChE inhibitory and antioxidant activity. Five compounds showed weak AChE inhibition and three of them exhibited high antioxidant activity.

Discovery of a Novel Acetylcholinesterase Inhibitor by Fragment-Based Design and Virtual Screening.

Despite extensive and intensive research efforts in recent decades, there is still no effective treatment for neurodegenerative diseases. On this background, the use of drugs inhibiting the enzyme acetylcholinesterase (AChE) remains an eternal evergreen in the symptomatic treatment of mild to moderate cognitive impairments. Even more, the cholinergic hypothesis, somewhat forgotten in recent years due to the shift in focus on amyloid cascade, is back to life, and the search for new, more effective AChE inhibitors continues. We generated a fragment-based library containing aromatic moieties and linkers originating from a set of novel AChE inhibitors. We used this library to design 1220 galantamine (GAL) derivatives following the model GAL (binding core) - linker (L) - aromatic fragment (Ar). The newly designed compounds were screened virtually for blood-brain barrier (BBB) permeability and binding to AChE. Among the top 10 best-scored compounds, a representative lead molecule was selected and tested for anti-AChE activity and neurotoxicity. It was found that the selected compound was a powerful non-toxic AChE inhibitor, 68 times more active than GAL, and could serve as a lead molecule for further optimization and development.

Role of Catalyst in Optimizing Fluid Catalytic Cracking Performance During Cracking of H-Oil-Derived Gas Oils.

Three H-Oil gas oils, heavy atmospheric gas oil (HAGO), light vacuum gas oil (LVGO), heavy vacuum gas oil (HVGO), and two their blends with hydrotreated straight run vacuum gas oils (HTSRVGOs) were cracked on two high unit cell size (UCS) lower porosity commercial catalysts and two low UCS higher porosity commercial catalysts. The cracking experiments were performed in an advanced cracking evaluation fluid catalytic cracking (FCC) laboratory unit at 527 °C, 30 s catalyst time on stream, and catalyst-to-oil (CTO) variation between 3.5 and 7.5 wt/wt The two high UCS lower porosity catalysts were more active and more coke selective. However, the difference between conversion of the more active high UCS lower porosity and low UCS higher porosity catalysts at 7.5 wt/wt CTO decreased in the order 10% (HAGO) > 9% (LVGO) > 6% (HVGO) > 4% (80% HTSRVGO/20% H-Oil VGO). Therefore, the catalyst performance is feedstock-dependent. The four studied catalysts along with a blend of one of them with 2% ZSM-5 were examined in a commercially revamped UOP FCC VSS unit. The lower UCS higher porosity catalysts exhibited operation at a higher CTO ratio achieving a similar conversion level with more active higher UCS lower porosity catalysts. However, the higher UCS lower porosity catalysts made 0.67% Δ coke that was higher than the maximum acceptable limit of 0.64% for this particular commercial FCC unit (FCCU), which required excluding the HVGO from the FCC feed blend. The catalyst system containing ZSM-5 increased the LPG yield but did not have an impact on gasoline octane. It was found that the predominant factor that controls refinery profitability related to the FCCU performance is the FCC slurry oil (bottoms) yield.

Commercial Investigation of the Ebullated-Bed Vacuum Residue Hydrocracking in the Conversion Range of 55-93.

The LUKOIL Neftohim Burgas vacuum residue hydrocracking has increased the vacuum residue conversion from 55 to 93% as a result of a proper feed selection, optimal catalyst condition, and the use of a Mo nanodispersed catalyst. It was found that the feed colloidal instability index estimated from the feed saturates, aromatics, resins, and asphaltenes (SARA) data negatively correlated with the conversion. Correlations based on the use of the nonlinear least-squares method, which relates the density to the aromatic structure contents for the straight run and hydrocracked vacuum residues, were developed. Intercriteria analysis was applied to evaluate the relations between the different properties of the straight run and the hydrocracked vacuum residual oils. The density of the hydrocracked vacuum residue measured by dilution with toluene was found to strongly correlate with the conversion, Conradson carbon content, softening point, and Fraasss breaking point.

Blood pressure distribution and control in coronary patients from 24 European countries in the European Society of Cardiology EURoObservational Research Programme European survey of cardiovascular disease prevention and diabetes. EUROASPIRE IV Registry.

BACKGROUND: Hypertension is the most prevalent major independent risk factor for developing coronary heart disease (CHD). The present analysis aimed to assess blood pressure (BP) distribution and factors associated with insufficient BP control in coronary patients from 24 countries participating in the European Society of Cardiology (ESC) EURoObservational Research Programme (EORP) EUROASPIRE IV survey. METHODS: EUROASPIRE IV is a cross-sectional study conducted in 2012-2013 in patients aged 80 years or less hospitalized for CHD with a follow-up visit at a median of 16 months later. Logistic regression analysis was applied to confirm factors associated with BP control defined as less than 140/90 mmHg for nondiabetic patients and less than 140/85 mmHg for diabetic patients. RESULTS: A total of 7998 patients (response rate, 48.7%) attended the follow-up visit. Complete data were available in 7653 participants (mean age 62.5 ±â€Š9.6 years). The BP goal was achieved in 57.6%. Patients failing to achieve the BP goal were older, had higher BMI, had more often a history of coronary artery bypass grafting (CABG) and reported diabetes more frequently. Logistic regression confirmed the following independent significant predictors of not achieving the BP goal: a history of diabetes [odds ratio (OR) 1.75], obesity (OR 1.70 vs. normal BMI), overweight (OR 1.28 vs. normal BMI), age at least 65 years (OR 1.53) and CABG as the index event (OR 1.26 vs. acute MI). CONCLUSION: EUROASPIRE IV found insufficient BP control in a large proportion of patients with stable CHD, with diabetes, increased BMI, older age and CABG as the index event being independent predictors of poor BP control.

Comparison of Low-Density Lipoprotein Cholesterol Assessment by Martin/Hopkins Estimation, Friedewald Estimation, and Preparative Ultracentrifugation: Insights From the FOURIER Trial.

Importance: Recent studies have shown that Friedewald underestimates low-density lipoprotein cholesterol (LDL-C) at lower levels, which could result in undertreatment of high-risk patients. A novel method (Martin/Hopkins) using a patient-specific conversion factor provides more accurate LDL-C levels. However, this method has not been tested in proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor-treated patients. Objective: To investigate accuracy of 2 different methods for estimating LDL-C levels (Martin/Hopkins and Friedewald) compared with gold standard preparative ultracentrifugation (PUC) in patients with low LDL-C levels in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Patients With Elevated Risk (FOURIER) trial. Design, Setting, and Participants: The FOURIER trial was a randomized clinical trial of evolocumab vs placebo added to statin therapy in 27 564 patients with stable atherosclerotic cardiovascular disease. The patients' LDL-C levels were assessed at baseline, 4 weeks, 12 weeks, 24 weeks, and every 24 weeks thereafter, and measured directly by PUC when the level was less than 40 mg/dL per the Friedewald method (calculated as non-HDL-C level - triglycerides/5). In the Martin/Hopkins method, patient-specific ratios of triglycerides to very low-density lipoprotein cholesterol (VLDL-C) ratios were determined and used to estimate VLDL-C, which was subtracted from the non-HDL-C level to obtain the LDL-C level. Main Outcomes and Measures: Low-density lipoprotein cholesterol calculated by the Friedewald and Martin/Hopkins methods, with PUC as the reference method. Results: For this analysis, the mean (SD) age was 62.7 (9.0) years; 2885 of the 12 742 patients were women (22.6%). A total of 56 624 observations from 12 742 patients had Friedewald, Martin/Hopkins, and PUC LDL-C measurements. The median difference from PUC LDL-C levels for Martin/Hopkins LDL-C levels was -2 mg/dL (interquartile range [IQR], -4 to 1 mg/dL) and for Friedewald LDL-C levels was -4 mg/dL (IQR, -8 to -1 mg/dL; P < .001). Overall, 22.9% of Martin/Hopkins LDL-C values were more than 5 mg/dL different than PUC values, and 2.6% were more than 10 mg/dL different than PUC levels. These were significantly less than respective proportions with Friedewald estimation (40.1% and 13.3%; P < .001), mainly because of underestimation by the Friedewald method. The correlation with PUC LDL-C was significantly higher for Martin/Hopkins vs Friedewald (ρ, 0.918 [95% CI 0.916-0.919] vs ρ, 0.867 [0.865-0.869], P < .001). Conclusions and Relevance: In patients achieving low LDL-C with PCSK9 inhibition, the Martin/Hopkins method for LDL-C estimation more closely approximates gold standard PUC than Friedewald estimation does. The Martin/Hopkins method may prevent undertreatment because of LDL-C underestimation by the Friedewald method. Trial Registration: ClinicalTrials.gov Identifier: NCT01764633.

Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions.

Background European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV in primary care was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational Research Programme in 2014-2015 in 71 centres from 14 European countries. The main objective was to determine whether the 2012 Joint European Societies' guidelines on cardiovascular disease (CVD) prevention in people at high CVD risk have been followed in clinical practice. Methods Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or glucose-lowering treatments were identified and interviewed at least six months after the start of medication. Results Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight (body mass index (BMI)≥25 and <30 kg/m2), 43.5% obese (BMI ≥30 kg/m2) and 63.9% centrally obese (waist circumference of ≥88 cm for women, ≥102 cm for men). The medical risk factor control was very poor, with less than half (42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipoprotein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the glycated haemoglobin (HbA1c) target of <7.0%. Conclusion The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts must be taken to improve cardiovascular prevention in people at high CVD risk.

Lifestyle and risk factor management in people at high cardiovascular risk from Bulgaria, Croatia, Poland, Romania and the United Kingdom who participated in both the EUROASPIRE III and IV primary care surveys.

OBJECTIVE: The objective of this study was to determine time trends in the implementation of European guidelines on the management of cardiovascular disease prevention in people at high cardiovascular risk. METHODS: Cardiovascular disease prevention as reflected in the primary care arms of the EUROASPIRE III and IV surveys were compared in centres from Bulgaria, Croatia, Poland, Romania and the United Kingdom that participated in both surveys. All patients were free of cardiovascular disease but considered at high cardiovascular disease risk since they had been started on blood pressure and/or lipid and/or glucose lowering treatments. They were interviewed and examined by means of standardized methods ≥6 months after the start of therapy. RESULTS: EUROASPIRE III comprised 2604 and EUROASPIRE IV 3286 subjects whereof 76% and 56% were interviewed. There were no major differences between the two surveys in age, gender, centres and reasons for inclusion. The prevalence of smoking was similar between EUROASPIRE III and IV. The proportion of smokers who did not intend to quit was significantly greater in EUROASPIRE IV compared with III. The prevalence of overweight or obesity was high and identical in both surveys. No significant differences were observed in physical activity. In participants not on blood pressure lowering treatment an elevated blood pressure was observed in 47% in both EUROASPIRE III and IV. In participants not on lipid lowering drugs the low-density lipoprotein cholesterol was ≥2.5 mmol/l in 87% and 88% in EUROASPIRE III and IV respectively. In participants free from known diabetes fasting plasma glucose was ≥7 mmol/l in 12% and 18% in EUROASPIRE III and IV. In subjects with known arterial hypertension blood pressure was at or below guideline recommended targets in 28% in EUROASPIRE III and 35% in IV. In participants on lipid lowering drugs the low-density lipoprotein cholesterol was < 2.5 mmol/l in 28% and 37% in EUROASPIRE III and IV. Glycated haemoglobin was < 7.0% in participants with known diabetes in 62% and 60% in EUROASPIRE III and IV. CONCLUSIONS: The results from EUROASPIRE III and IV clearly demonstrate that the control of modifiable risk factors in people at high cardiovascular disease risk remains poor.

Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project.

AIMS: The EUROASPIRE III survey indicated that the guidelines on cardiovascular disease prevention are poorly implemented in patients with established coronary heart disease (CHD). The purpose of this health economic project was to assess the potential clinical effectiveness and cost-effectiveness of optimizing cardiovascular prevention in eight EUROASPIRE III countries (Belgium, Bulgaria, Croatia, Finland, France, Italy, Poland, and the U.K.). METHODS AND RESULTS The individual risk for subsequent cardiovascular events was estimated, based on published Framingham equations. Based on the EUROASPIRE III data, the type of suboptimal prevention, if any, was identified for each individual, and the effects of optimized tailored prevention (smoking cessation, diet and exercise, better management of elevated blood pressure and/or LDL-cholesterol) were estimated. Costs of prevention and savings of avoided events were based on country-specific data. A willingness to pay threshold of €30,000/quality-adjusted life year (QALY) was used. The robustness of the results was validated by sensitivity analyses. Overall, the cost-effectiveness analyses for the eight countries showed mainly favourable results with an average incremental cost-effectiveness ratio (ICER) of €12,484 per QALY. Only in the minority of patients at the lowest risk for recurrent events, intensifying preventive therapy seems not cost-effective. Also, the single impact of intensified cholesterol control seems less cost-effective, possibly because their initial 2-year risk was already fairly low, hence the room for improvement is rather limited. CONCLUSION: These results underscore the societal value of optimizing prevention in most patients with established CHD, but also highlight the need for setting priorities towards patients more at risk and the need for more studies comparing intensified prevention with usual care in these patients.