RESUMO
Angiotensin-converting enzyme 2 (ACE2) protects against organ damage in hypertension and cardiovascular diseases by counter regulating the renin-angiotensin system (RAS). ACE2 is also the receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Based on the claim that RAS inhibitors (RASIs) cause ACE2 overexpression in some animal experiments, concerns have arisen that RASIs may aggravate SARS-CoV-2 infection and coronavirus disease-2019 severity in RASI-treated patients. To achieve a comprehensive review, a systematic search of MEDLINE/PubMed was conducted regarding the effects of RASIs on tissue ACE2 mRNA/protein expression in healthy animals and animal models of human diseases. We identified 88 eligible articles involving 168 experiments in the heart, kidneys, lungs, and other organs. Three of 38 experiments involving healthy animals showed ACE2 expression greater than twice that of the control (overexpression). Among 102 disease models (130 experiments), baseline ACE2 was overexpressed in 16 models (18 experiments) and less than half the control level (repression) in 28 models (40 experiments). In 72 experiments, RASIs did not change ACE2 levels from the baseline levels of disease models. RASIs caused ACE2 overexpression compared to control levels in seven experiments, some of which were unsupported by other experiments under similar conditions. In 36 experiments, RASIs reversed or prevented disease-induced ACE2 repression, yielding no or marginal changes. Therefore, ACE2 overexpression appears to be a rare rather than common consequence of RASI treatment in healthy animals and disease models. Future studies should clarify the pathophysiological significance of RASI-induced reversal or prevention of ACE2 repression in disease models.
Assuntos
Enzima de Conversão de Angiotensina 2/metabolismo , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Hipertensivos/efeitos adversos , Expressão Gênica/efeitos dos fármacos , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Animais , Anti-Hipertensivos/farmacologia , COVID-19 , Modelos Animais de Doenças , MEDLINE , Sistema Renina-Angiotensina/efeitos dos fármacosRESUMO
The rapid spread of a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to an ongoing pandemic of coronavirus disease 2019 (COVID-19). Recently, angiotensin-converting enzyme 2 (ACE2) has been shown to be a functional receptor for SARS-CoV-2 to enter host target cells. Given that angiotensin receptor blockers (ARBs) and an ACE inhibitor (ACEI) upregulated ACE2 expression in animal studies, the concern might arise regarding whether ARBs and ACEIs would increase the morbidity and mortality of COVID-19. On the other hand, animal data suggested a potential protective effect of ARBs against COVID-19 pneumonia because an ARB prevented the aggravation of acute lung injury in mice infected with SARS-CoV, which is closely related to SARS-CoV-2. Importantly, however, there is no clinical or experimental evidence supporting that ARBs and ACEIs either augment the susceptibility to SARS-CoV-2 or aggravate the severity and outcomes of COVID-19 at present. Until further data are available, it is recommended that ARB and ACEI medications be continued for the treatment of patients with cardiovascular disease and hypertension, especially those at high risk, according to guideline-directed medical therapy based on the currently available evidence.
Assuntos
Angiotensina II/fisiologia , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Betacoronavirus , Infecções por Coronavirus/etiologia , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/etiologia , Enzima de Conversão de Angiotensina 2 , Animais , COVID-19 , Humanos , Pandemias , SARS-CoV-2RESUMO
A role of interferon-gamma is suggested in early development of atherosclerosis. However, the role of interferon-gamma in progression and destabilization of advanced atherosclerotic plaques remains unknown. Thus, the aim of this study was to determine whether postnatal inhibition of interferon-gamma signaling could inhibit progression of atherosclerotic plaques and stabilize the lipid- and macrophage-rich advanced plaques. Atherosclerotic plaques were induced in ApoE-knockout (KO) mice by feeding high-fat diet from 8 weeks old (w). Interferon-gamma function was postnatally inhibited by repeated gene transfers of a soluble mutant of interferon-gamma receptors (sIFNgammaR), an interferon-gamma inhibitory protein, into the thigh muscle every 2 weeks. When sIFNgammaR treatment was started at 12 w (atherosclerotic stage), sIFNgammaR not only prevented plaque progression but also stabilized advanced plaques at 16 w: sIFNgammaR decreased accumulations of the lipid and macrophages and increased fibrotic area with more smooth muscle cells. Moreover, sIFNgammaR downregulated expressions of proinflammatory cytokines, chemokines, adhesion molecules, and matrix metalloproteinases but upregulated procollagen type I. sIFNgammaR did not affect serum cholesterol levels. In conclusion, postnatal blocking of interferon-gamma function by sIFNgammaR treatment would be a new strategy to inhibit plaque progression and to stabilize advanced plaques through the antiinflammatory effects.
Assuntos
Apolipoproteínas E/genética , Aterosclerose/terapia , Terapia Genética/métodos , Interferon gama/metabolismo , Receptores de Interferon/genética , Animais , Aorta/patologia , Aterosclerose/imunologia , Aterosclerose/patologia , Antígenos CD40/metabolismo , Ligante de CD40/metabolismo , Gorduras na Dieta/farmacologia , Técnicas de Transferência de Genes , Interferon gama/antagonistas & inibidores , Interferon gama/imunologia , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Plasmídeos , Receptores de Interferon/imunologia , Receptores de Interferon/metabolismo , Fator de Transcrição STAT1/metabolismo , Transdução de Sinais/imunologia , Receptor de Interferon gamaRESUMO
While it is important to treat lifestyle-related diseases for the primary and secondary prevention of cardiovascular diseases, medication adherence is still poor. Although various causes of poor adherence have been reported, the differences between physicians and their patients regarding the recognition of medication adherence have not been well-investigated.We administered a questionnaire about medication adherence to 300 outpatients and their 23 cardiologists at the Department of Cardiology, Fukuoka University Hospital. The questionnaires for patients and physicians included acceptable total number of drug doses and dosing schedule, forgetting to take the medicine, and dose-reduction or -increase based on self-judgement. The patients were 70.6â±â12.3 years old and 61.0% (nâ=â183) were male. Patients reported that it was acceptable to receive 0-5 doses twice daily. The patients were divided into two groups: an agreement group, in which physicians and their patients had the same answer to the question regarding forgetting medication (203 cases; 67.7%), and a disagreement group (97 cases; 32.3%). Overall, the inter-rater agreement between physicians and patients with regard to forgetting medication was significant, but slight (κ coefficientâ=â0.12). In a multivariate analysis, absence of hypertension [odds ratio (OR): 0.21, 95% confidence interval (CI): 0.09-0.50, Pâ<â.001), ß-blocker usage (OR: 1.86, 95% CI: 1.11-3.12, Pâ=â.02), and biguanide usage (OR: 4.04, 95% CI: 1.43-11.41, Pâ=â.01) were independent predictors of disagreement with regard to forgetting medication.The inter-rater agreement between physicians and patients with regard to medication adherence was slight. An increase in inter-rater agreement should improve medication adherence.
Assuntos
Doenças Cardiovasculares/tratamento farmacológico , Hipertensão/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Relações Médico-Paciente/ética , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Doenças Cardiovasculares/psicologia , Feminino , Humanos , Hipertensão/psicologia , Japão/epidemiologia , Estilo de Vida , Masculino , Adesão à Medicação/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prevenção Secundária , Autorrelato/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
We investigated whether blocking of monocyte chemoattractant-1 (MCP-1) function would inhibit recruitment of tumor-associated macrophages (TAMs) and prevent tumor angiogenesis and tumor growth of human malignant melanoma. B16-F1 melanoma cells were implanted onto the back of C57BL/6 mice (Day 0). At Day 7, a dominant negative MCP-1 mutant (7ND) gene was transfected in the thigh muscle to make overexpressed 7ND protein secreted into systemic circulation. 7ND treatment inhibited TAM recruitment and partially reduced tumor angiogenesis and tumor growth. Also, 7ND treatment attenuated inductions of tumor necrosis factor-alpha (TNFalpha), interleukin-1alpha (IL-1alpha), and vascular endothelial growth factor (VEGF) in the stroma and tumor. Melanoma cells expressed not only MCP-1 but also its receptor CCR2. Accordingly, it was suggested that MCP-1 would enhance tumor angiogenesis and early tumor growth in the early stages by inducing TNFalpha, IL-1alpha, and VEGF through TAM recruitment and probably the direct autocrine/paracrine effects on melanoma cells.
Assuntos
Quimiocina CCL2/genética , Terapia Genética/métodos , Melanoma/genética , Melanoma/terapia , Neovascularização Patológica/genética , Neovascularização Patológica/prevenção & controle , Animais , Linhagem Celular Tumoral , Proliferação de Células , Quimiocina CCL2/uso terapêutico , Humanos , Camundongos , Camundongos Endogâmicos C57BL , MutaçãoRESUMO
It is unknown whether interferon-gamma has a positive or negative impact on atherosclerotic plaque formation. Thus, we examined the effects of postnatal interferon-gamma function blocking on plaque formation in apolipoprotein E-knockout (apoEKO) mice by overexpressing a soluble mutant of interferon-gamma receptor (sIFNgammaR), an interferon-gamma inhibitory protein. Mice were fed a Western-type diet from 8 weeks of age. sIFNgammaR or mock plasmid (control) was injected into the thigh muscle at 8 and 10 weeks' age, because serum sIFNgammaR protein was transiently increased with a peak at 2 days after a single sIFNgammaR gene transfer and remained elevated for 2 weeks. At 12 weeks' age, control apoEKO mice showed marked atherosclerotic plaques from the ascending aorta to the aortic arch. The plaques in the aortic root had massive lipid cores and macrophage infiltration with thin fibrous cap and few smooth muscle cells, demonstrating low plaque stability. In contrast, the luminal plaque area was remarkably reduced in sIFNgammaR-treated apoEKO mice. sIFNgammaR treatment not only reduced lipid core areas and macrophage infiltration but also increased smooth muscle cell count and fibrotic area, suggesting improved plaque stability. In controls, interleukin-1beta, monocyte chemoattractant protein-1, and vascular cell adhesion molecules-1 were remarkably upregulated in the aortic wall. These changes were significantly reversed by sIFNgammaR. sIFNgammaR treatment had no effects on serum cholesterol levels. In conclusion, sIFNgammaR treatment prevented plaque formation in apoEKO mice by inhibiting inflammatory changes in the arterial wall. The present study provides insight into a new strategy for preventing atherosclerosis.
Assuntos
Apolipoproteínas E/fisiologia , Aterosclerose/prevenção & controle , Aterosclerose/fisiopatologia , Interferon gama/antagonistas & inibidores , Interferon gama/fisiologia , Receptores de Interferon/fisiologia , Animais , Aorta/metabolismo , Aorta/patologia , Apolipoproteínas E/genética , Aterosclerose/etiologia , Proteína C-Reativa/metabolismo , Quimiocina CCL2/genética , Quimiocina CCL2/metabolismo , HDL-Colesterol/sangue , DNA/genética , DNA/farmacologia , Regulação da Expressão Gênica/efeitos dos fármacos , Interleucina-1beta/genética , Interleucina-1beta/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Monócitos/patologia , Peritonite/fisiopatologia , Receptores de Interferon/genética , Molécula 1 de Adesão de Célula Vascular/genética , Molécula 1 de Adesão de Célula Vascular/metabolismo , Receptor de Interferon gamaRESUMO
BACKGROUND: Excessive myocardial fibrosis impairs cardiac function in hypertensive hearts. Roles of transforming growth factor (TGF)-beta in myocardial remodeling and cardiac dysfunction were examined in pressure-overloaded rats. METHODS AND RESULTS: Pressure overload was induced by a suprarenal aortic constriction in Wistar rats. Fibroblast activation (proliferation and phenotype transition to myofibroblasts) was observed after day 3 and peaked at days 3 to 7. Thereafter, myocyte hypertrophy and myocardial fibrosis developed by day 28. At day 28, echocardiography showed normal left ventricular fractional shortening, but the decreased ratio of early to late filling velocity of the transmitral Doppler velocity and hemodynamic measurement revealed left ventricular end-diastolic pressure elevation, indicating normal systolic but abnormal diastolic function. Myocardial TGF-beta mRNA expression was induced after day 3, peaked at day 7, and remained modestly increased at day 28. An anti-TGF-beta neutralizing antibody, which was administered intraperitoneally daily from 1 day before operation, inhibited fibroblast activation and subsequently prevented collagen mRNA induction and myocardial fibrosis, but not myocyte hypertrophy. Neutralizing antibody reversed diastolic dysfunction without affecting blood pressure and systolic function. CONCLUSIONS: TGF-beta plays a causal role in myocardial fibrosis and diastolic dysfunction through fibroblast activation in pressure-overloaded hearts. Our findings may provide an insight into a new therapeutic strategy to prevent myocardial fibrosis and diastolic dysfunction in pressure-overloaded hearts.
Assuntos
Cardiomegalia/patologia , Miocárdio/patologia , Fator de Crescimento Transformador beta/antagonistas & inibidores , Disfunção Ventricular Esquerda/prevenção & controle , Animais , Anticorpos/farmacologia , Cardiomegalia/metabolismo , Cardiomegalia/fisiopatologia , Diástole , Fibroblastos/metabolismo , Fibrose , Hemodinâmica , Hipertensão/patologia , Hipertensão/fisiopatologia , Cinética , Masculino , Miocárdio/citologia , Miocárdio/metabolismo , Pressão , RNA Mensageiro/biossíntese , Ratos , Ratos Wistar , Fator de Crescimento Transformador beta/imunologia , Fator de Crescimento Transformador beta/fisiologia , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Flushing is one of the most common vasodilation-related adverse effects associated with Ca(2+) channel antagonist treatment. This symptom is known to occur more frequently in women than men. The present study aimed at investigating the effect of ovariectomy on nifedipine-induced flushing in mice. Ovariectomy markedly increased the tail skin temperature, a parameter of skin flushing, induced by nifedipine at a dose showing no influence on blood pressure. This event was blocked by estradiol replacement. Estrogen withdrawal is, therefore, included in the risk factors for nifedipine-induced flushing and this risk is lessened by estrogen replacement.
Assuntos
Rubor/etiologia , Nifedipino/farmacologia , Ovariectomia/efeitos adversos , Pele/efeitos dos fármacos , Vasodilatadores/farmacologia , Análise de Variância , Animais , Relação Dose-Resposta a Droga , Estradiol/farmacologia , Feminino , Camundongos , Camundongos Endogâmicos ICR , Pele/irrigação sanguínea , Pele/fisiopatologia , Temperatura Cutânea/efeitos dos fármacos , CaudaRESUMO
The present study was designed to clarify the involvement of nitric oxide (NO) signaling in the adverse effect of cyclosporine on the blood-brain barrier. Cyclosporine increased the permeability of sodium-fluorescein and the cellular accumulation of rhodamine 123, a substrate of P-glycoprotein, in mouse brain endothelial (MBEC4) cells. This effect was markedly enhanced two- to threefold when MBEC4 cells were cocultured with rat astrocytes or C6 glioma cells. Direct and continuous electrochemical measurement of NO demonstrated that cyclosporine dose-dependently increased histamine- and phenylephrine-evoked NO production in MBEC4 cells and astrocytes, respectively. A NO synthase inhibitor (NG-monomethyl-L-arginine) blocked slightly and markedly cyclosporine-induced impairment of the endothelial barrier in the monolayer and coculture system, respectively. These findings suggest that cyclosporine impairs the brain endothelial barrier function by accelerating NO production in the brain endothelial and astroglial cells. This event may be interpreted as triggering the occurrence of cyclosporine neurotoxicity.
Assuntos
Astrócitos/efeitos dos fármacos , Barreira Hematoencefálica/efeitos dos fármacos , Ciclosporina/farmacologia , Células Endoteliais/efeitos dos fármacos , Óxido Nítrico/fisiologia , Subfamília B de Transportador de Cassetes de Ligação de ATP/fisiologia , Animais , Animais Recém-Nascidos , Astrócitos/citologia , Astrócitos/metabolismo , Barreira Hematoencefálica/metabolismo , Encéfalo/citologia , Encéfalo/efeitos dos fármacos , Encéfalo/metabolismo , Linhagem Celular Transformada , Linhagem Celular Tumoral , Permeabilidade da Membrana Celular/efeitos dos fármacos , Sobrevivência Celular/efeitos dos fármacos , Técnicas de Cocultura , Relação Dose-Resposta a Droga , Células Endoteliais/metabolismo , Inibidores Enzimáticos/farmacologia , Fluoresceína/metabolismo , Camundongos , Camundongos Endogâmicos BALB C , Óxido Nítrico/biossíntese , Óxido Nítrico Sintase/antagonistas & inibidores , Óxido Nítrico Sintase/metabolismo , Ratos , Ratos Wistar , Rodamina 123/metabolismo , ômega-N-Metilarginina/farmacologiaRESUMO
In this study, we investigated the effect of cyclosporin A on the binding properties of the GABAA receptor in the hippocampus, known to be responsible for the induction of seizures, to clarify the mechanism of cyclosporin A-inhibited GABA neurotransmission in ovariectomized rats, as a climacterium model. The effects of single and subchronic treatments with cyclosporin A were examined on [3H]muscimol binding to hippocampal synaptosomal membranes in sham, ovariectomized, and estradiol/ovariectomized rats. A single treatment with cyclosporin A (40 mg/kg, i.p.) failed to change [3H]muscimol binding in the 3 groups, when compared with each corresponding vehicle-treated group. Subchronic treatment with cyclosporin A (40 mg/kg, i.p., once a day for 5 days) significantly decreased the amount of [3H]muscimol binding in ovariectomized rats. However, this inhibitory effect was not observed in sham or estradiol/ovariectomized rats. These results demonstrated that the binding activity of the GABAA receptor was decreased in ovariectomized rats after subchronic cyclosporin A treatment. This study supports the hypothesis that ovariectomy elevates the susceptibility to cyclosporin A-induced convulsions by accelerating the inhibitory actions of cyclosporin A on GABA neurotransmission in the hippocampus.
Assuntos
Ciclosporina/farmacologia , Imunossupressores/farmacologia , Ovariectomia , Receptores de GABA-A/efeitos dos fármacos , Animais , Depressão Química , Estradiol/farmacologia , Feminino , Agonistas GABAérgicos/metabolismo , Muscimol/metabolismo , Ratos , Ratos WistarRESUMO
Diastolic dysfunction is more prevalent in individuals with hypertension, particularly postmenopausal women; however, the pathogenesis of diastolic dysfunction remains unknown. Pressure overload activates cardiac inflammation, which induces myocardial fibrosis and diastolic dysfunction in rats with a suprarenal aortic constriction (AC). Therefore, we examined the effects of bilateral ovariectomy (OVX) on left ventricle (LV) remodeling, diastolic dysfunction and cardiac inflammation in hypertensive female rats. Rats were randomized to OVX+AC, OVX and AC groups as well as a Control group receiving sham operations for both the procedures. Rats underwent OVX at 6 weeks and AC at 10 weeks (Day 0). At Day 28, OVX did not appear to affect arterial pressure, cardiac hypertrophy or LV fractional shortening in AC rats. However, OVX increased myocardial fibrosis, elevated LV end-diastolic pressure and reduced the transmitral Doppler spectra early to late filling velocity ratio in AC rats. AC-induced transient myocardial monocyte chemoattractant protein-1 expression and macrophage infiltration, both of which peaked at Day 3 and were augmented and prolonged by OVX. At Day 28, dihydroethidium staining revealed superoxide generation in the intramyocardial arterioles in the OVX+AC group but not in the AC group. NOX1, a functional subunit of nicotinamide adenine dinucleotide phosphate oxidase, was upregulated only in the OVX+AC group at Day 28. Chronic 17ß-estradiol replacement prevented the increases in macrophage infiltration, NOX1 upregulation, myocardial fibrosis and diastolic dysfunction in OVX+AC rats. In conclusion, we suggest that estrogen deficiency augments cardiac inflammation and oxidative stress and thereby aggravates myocardial fibrosis and diastolic dysfunction in hypertensive female rats. The findings provide insight into the mechanism underlying diastolic dysfunction in hypertensive postmenopausal women.
Assuntos
Fibrose Endomiocárdica/fisiopatologia , Estrogênios/deficiência , Hipertensão/fisiopatologia , Miocardite/fisiopatologia , Ovariectomia , Pós-Menopausa/fisiologia , Disfunção Ventricular Esquerda/fisiopatologia , Animais , Diástole/fisiologia , Modelos Animais de Doenças , Fibrose Endomiocárdica/metabolismo , Fibrose Endomiocárdica/prevenção & controle , Estradiol/uso terapêutico , Feminino , Humanos , Hipertensão/metabolismo , Miocardite/metabolismo , Miocardite/prevenção & controle , Óxido Nítrico Sintase Tipo III/metabolismo , Estresse Oxidativo/fisiologia , Ratos , Ratos Wistar , Superóxidos/metabolismo , Disfunção Ventricular Esquerda/metabolismo , Disfunção Ventricular Esquerda/prevenção & controle , Remodelação Ventricular/fisiologiaRESUMO
The aims of this study were to examine the enhancing effects of aloe-emodin anthrone (AEA) on the colonic membrane permeability of water-soluble and poorly permeable compounds and to clarify the mechanism of the permeation-enhancing activity of AEA. The permeation-enhancing activity of AEA was estimated from changes in the permeability coefficient of 5(6)-carboxyfluorescein (CF) in rat colonic mucosa using a Ussing-type chamber. Various inhibitors were used to investigate the mechanism of action of AEA. The structural change in the membrane and the cytotoxicity of AEA in the intestinal mucosa were evaluated by measuring the electrical resistance of the membrane (R(m)) and lactate dehydrogenase (LDH) activity, respectively. AEA significantly increased the permeation of CF in a dose-dependent manner. The enhanced permeability was significantly suppressed by a histamine H(1) receptor antagonist, pyrilamine, and a mast cell stabilizer, ketotifen, but not by a histamine H(2) receptor antagonist, cimetidine. The enhancing effect was also inhibited by an inhibitor of protein kinase C (PKC). Potential difference and short-circuit current values decreased, while R(m) values remained constant throughout the experiment. The addition of AEA to the mucosal solution decreased R(m) to 30%, but then remained constant. LDH activity with AEA was not significantly different from that of the control. In conclusion, AEA is a candidate for effective absorption enhancers without damage of the membrane and cytotoxicity. We propose that AEA stimulates mast cells within the colonic mucosa to release histamine, which probably bind to the H(1) receptor. The intracellular PKC route activated by H(1) receptor activation enhances the permeability of water-soluble and poorly permeable drugs via opening of tight junctions in rat colonic membrane.
Assuntos
Colo/metabolismo , Emodina/análogos & derivados , Emodina/farmacocinética , Mucosa Intestinal/metabolismo , Água/metabolismo , Animais , Antraquinonas , Colo/efeitos dos fármacos , Liberação de Histamina/efeitos dos fármacos , Liberação de Histamina/fisiologia , Técnicas In Vitro , Mucosa Intestinal/efeitos dos fármacos , Masculino , Permeabilidade/efeitos dos fármacos , Ratos , Ratos Wistar , Solubilidade/efeitos dos fármacosRESUMO
Hot flushes are one of the most frequent symptoms in menopausal women. We investigated effect of soybean isoflavones (Soyaflavone HG) on nifedipine-induced flushing in ovariectomized mice. Ovariectomy markedly aggravated nifedipine-induced increase in tail skin temperature. Soyaflavone HG (10 mg/kg, p.o., once a day for 5 days) inhibited nifedipine-induced flushing in ovariectomized mice. The inhibitory effect of Soyaflavone HG was significantly reversed by an estrogen-receptor antagonist, ICI 182,780, suggesting that Soyaflavone HG prevents nifedipine-induced flushing partially through estrogen receptors. We presented the experimental evidence suggesting that soybean isoflavones including Soyaflavone HG have the benefits for menopausal hot flushes.