Mutations in the chloroquine resistance transporter (PfCRT) are the primary determinant of chloroquine (CQ) resistance in the malaria parasite Plasmodium falciparum. A number of distinct PfCRT haplotypes, containing between 4 and 10 mutations, have given rise to CQ resistance in different parts of the world. Here we present a detailed molecular analysis of the number of mutations (and the order of addition) required to confer CQ transport activity upon the PfCRT as well as a kinetic characterization of diverse forms of PfCRT. We measured the ability of more than 100 variants of PfCRT to transport CQ when expressed at the surface of Xenopus laevis oocytes. Multiple mutational pathways led to saturable CQ transport via PfCRT, but these could be separated into two main lineages. Moreover, the attainment of full activity followed a rigid process in which mutations had to be added in a specific order to avoid reductions in CQ transport activity. A minimum of two mutations sufficed for (low) CQ transport activity, and as few as four conferred full activity. The finding that diverse PfCRT variants are all limited in their capacity to transport CQ suggests that resistance could be overcome by reoptimizing the CQ dosage.drug resistance | evolutionary biochemistry | Xenopus oocytes

The prevention and treatment of malaria is heavily dependent on antimalarial drugs. However, beginning with the emergence of chloroquine (CQ)-resistant Plasmodium falciparum parasites 50 years ago, efforts to control the disease have been thwarted by failed or failing drugs. Mutations in the parasite's 'chloroquine resistance transporter' (PfCRT) are the primary cause of CQ resistance. Furthermore, changes in PfCRT (and in several other transport proteins) are associated with decreases or increases in the parasite's susceptibility to a number of other antimalarial drugs. Here, we review recent advances in our understanding of CQ resistance and discuss these in the broader context of the parasite's susceptibilities to other quinolines and related drugs. We suggest that PfCRT can be viewed both as a 'multidrug-resistance carrier' and as a drug target, and that the quinoline-resistance mechanism is a potential 'Achilles' heel' of the parasite. We examine a number of the antimalarial strategies currently undergoing development that are designed to exploit the resistance mechanism, including relatively simple measures, such as alternative CQ dosages, as well as new drugs that either circumvent the resistance mechanism or target it directly.

Background: Mutations in the chloroquine resistance transporter (PfCRT) change the susceptibility of Plasmodium falciparum to diverse antimalarial drugs.Results: In addition to chloroquine, PfCRT transports quinine, quinidine, and verapamil, which bind to distinct but antagonistically interacting sites.Conclusion: PfCRT is a multidrug carrier with a polyspecific drug-binding cavity.Significance: These findings could be used to develop high affinity inhibitors of PfCRT.

Mutations in the Plasmodium falciparum ‘chloroquine resistance transporter’ (PfCRT) confer resistance to chloroquine (CQ) and related antimalarials by enabling the protein to transport these drugs away from their targets within the parasite’s digestive vacuole (DV). However, CQ resistance-conferring isoforms of PfCRT (PfCRTCQR) also render the parasite hypersensitive to a subset of structurally-diverse pharmacons. Moreover, mutations in PfCRTCQR that suppress the parasite’s hypersensitivity to these molecules simultaneously reinstate its sensitivity to CQ and related drugs. We sought to understand these phenomena by characterizing the functions of PfCRTCQR isoforms that cause the parasite to become hypersensitive to the antimalarial quinine or the antiviral amantadine. We achieved this by measuring the abilities of these proteins to transport CQ, quinine, and amantadine when expressed in Xenopus oocytes and complemented this work with assays that detect the drug transport activity of PfCRT in its native environment within the parasite. Here we describe two mechanistic explanations for PfCRT-induced drug hypersensitivity. First, we show that quinine, which normally accumulates inside the DV and therewithin exerts its antimalarial effect, binds extremely tightly to the substrate-binding site of certain isoforms of PfCRTCQR. By doing so it likely blocks the normal physiological function of the protein, which is essential for the parasite’s survival, and the drug thereby gains an additional killing effect. In the second scenario, we show that although amantadine also sequesters within the DV, the parasite’s hypersensitivity to this drug arises from the PfCRTCQR-mediated transport of amantadine from the DV into the cytosol, where it can better access its antimalarial target. In both cases, the mutations that suppress hypersensitivity also abrogate the ability of PfCRTCQR to transport CQ, thus explaining why rescue from hypersensitivity restores the parasite’s sensitivity to this antimalarial. These insights provide a foundation for understanding clinically-relevant observations of inverse drug susceptibilities in the malaria parasite.

Our findings reveal that the PfCRT(Dd2)-mediated transport of tricyclic antimalarials reduces the parasite's susceptibility to these drugs.

Hypermobility syndrome usually causes pain in limbs from extension type injuries. The authors report on a 16-yr-old female adolescent with incapacitating chest pain secondary to extreme hypermobility of the chest. This pain led the patient to see multiple specialists without improvement or diagnosis. Physical examination results revealed a very hypermobile patient who was able to internally rotate her shoulders inward until her elbows touched. This unusual hyperextension maneuver was achieved by holding the shoulders in anteversion with her hands on her hips (see figures in the article). Currently, there is no literature reporting hypermobility as a cause for chronic chest pain. Pain medication including opioids did not reduce the patient's chronic chest pain. Specific physical therapy to strengthen core and chest wall muscles in addition to working on proper breathing techniques with the diaphragm decreased pain and resulted in a resolution of this condition. We report that hypermobility can cause significant chest pain and may require creative physical therapy to strengthen the specific musculature.

Glacier Benito is a temperate outlet glacier on the west side of the North Patagonian Icefield. Rates of thinning and ablation were obtained using data collected by the British Joint Services Expedition in 1972/73 and subsequent data collected in 2007 and 2011. Ice-front recession rates were based on dendrochronological dating for the terminal moraines and aerial and satellite imagery of the ice front in 1944, 1998 and 2002. Between the first Benito survey in 1973 and 2007, the lower glacier thinned by nearly 150 m at an average rate of 4.3 m yr −1 with the rate increasing to 6.1 m yr −1 between 2007 and 2011, a 28.7% increase during the latter period. Increases in ice movement and ablation were negligible: ice movement for 1973 and 2007 averaged 0.45 m day −1 and ablation averaged 0.05 m day −1 . Ice front recession along the glacier's centre line from 1886 to 2002 was approximately 1860 m. Retreat rates between 1886 and 1944 averaged 8.9 m yr −1 . Thereafter glacier asymmetry makes measurement along the glacier centre line unrepresentative of areal change until 1998 when symmetry was restored; retreat between 1944 and 1998 was 15.4 m yr −1 . From 1998 to 2002 the rate increased dramatically to 127.2 m yr −1 . Recession from the southern end of Benito's terminal moraine in the 1850s supports an early date for initial retreat of the Icefield's glaciers.

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