1416Combined therapy of empagliflozin and linagliptin is superior to metformin and insulin glargine in improving blood pressure and vascular function in type 2 diabetes

Background and purpose

The optimal choice of antidiabetic medication in patients that need combined therapy is under debate. The aim of this study was to analyze whether beyond glucose control the combination of empagliflozin (E) and linagliptin (L) improves blood pressure (BP) and vascular function in patients with type 2 diabetes (T2DM) as opposed to the combination of metformin (M) and insulin glargine (I).

Methods

This was a prospective, randomized, controlled, single center study including 101 patients with T2DM, who were randomized 1:1 to E 10–25mg combined with L 5mg once daily or M 850 or 1000mg twice daily combined with I once daily. All patients underwent BP measurement and vascular function analysis by validated systems at baseline and after 12 weeks of treatment.

Results

In comparison to baseline, office, 24-hour ambulatory BP as well as central blood and pulse pressure (PP) values decreased significantly after 12 weeks of treatment with E+L, whereas there was no change in the M+I group (see table). Twenty-four-hour peripheral systolic (mean difference: −5.2±1.5mmHg, p=0.004) and diastolic BP (−1.9±1.0mmHg, p=0.036), central clinical systolic BP (−5.56±1.9mmHg, p=0.009), forward pressure pulse height (−2.0±0.9mmHg, p=0.028), 24-h central systolic BP (−3.6±1.4mmHg, p=0.045) and 24-h pulse wave velocity (−0.14±0.05m/s, p=0.043) were reduced to a greater extent in the E+L than in the M+I group.

Empagliflozin+Linagliptin Metformin+Insulin Baseline 12 weeks p value Baseline 12 weeks p value Peripheral ambulatory BP values   24-h SBP [mmHg] 131.0±10.9 127.0±8.8 <0.001 131.0±9.7 131.0±8.6 0.438   24-h DBP [mmHg] 81.5±7.1 79.7±7.0 0.013 81.0±7.1 81.0±7.5 0.976 Clinical (laboratory) central vascular parameters   Central SBP [mmHg] 123.0±9.6 117.0±10.4 <0.001 121.0±9.9 121.0±8.3 0.944   Central PP [mmHg] 44.4±8.0 41.4±6.6 0.004 43.5±8.6 42.8±7.5 0.471   Forward pressure pulse height [mmHg] 33.0±5.7 30.2±4.6 <0.001 32.5±5.6 31.8±4.5 0.216   Central office PWV [m/s] 8.2±1.6 8.0±1.5 0.039 8.4±1.3 8.3±1.2 0.400 24-h ambulatory central vascular parameters   Central 24-h SBP [mmHg] 120.5±9.3 117.3±7.9 0.007 121.0±9.1 121.0±8.0 0.608   Central 24-h DBP [mmHg] 83.2±7.3 81.1±6.9 0.016 82.4±7.1 82.4±7.7 0.928   Central 24-h PWV [m/s] 8.9±1.3 8.8±1.3 0.010 9.0±1.4 9.0±1.3 0.349 SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse pressure; PWV, pulse wave velocity.

Conclusion

The combination of E+L significantly improves BP and vascular function in contrast to the combination of M+I.

Acknowledgement/Funding

This IIS was supported by a research grant from Boehringer Ingelheim International GmBH

P4993Tissue sodium concentration emerged as a determinant of hypertrophic vascular remodeling in type 2 diabetes

Background

Studies describe a linkage between greater sodium intake and higher incidence of organ damage and cardiovascular end points. Sodium intake is usually assessed by measuring 24-hour urinary sodium excretion, which is prone to high fluctuation. For the assessment of tissue sodium a new technique (23Na-MRI) has been developed. We analyzed whether tissue sodium is linked to vascular remodeling of small resistance vessels in patients with type-2 diabetes.

Methods

In patients with type 2 diabetes we assessed tissue sodium content and vascular structural parameters of the retinal arterioles, since structural changes of resistance vessels (150–300 μm) can be non-invasively and reliably assessed in the retinal circulation by Scanning Laser Doppler Flowmetry (SLDF). Patients with antidiabetic medication were off the therapy (antihypertensives were kept constant) for 4 weeks. The structural parameters of retinal arterioles assessed were outer- and inner diameter (OD & ID), wall thickness (WT), wall-to-lumen ratio (WLR) and wall cross sectional area (WCSA). Tissue sodium content was assessed non-invasively with a 3.0 T clinical MRI system in each patient. Subject placed their lower legs in the center of a 23Na knee coil and sodium content in skin and muscle (musculus triceps surae) were measured.

Results

In patients with type 2 diabetes (N=52) we observed a significant correlation between tissue sodium content (muscle and skin) and OD, WT and WCSA and a trend has been noticed between muscle sodium content and ID and WLR. Multiple linear regression analysis demonstrated that tissue sodium content is a significant determinant of hypertrophic vascular remodeling as indicated by increased WT and WCSA, independent of age, gender and 24-hour ambulatory diastolic blood pressure.

Correlation coefficients Muscle sodium content (mmol/l) Skin sodium content (mmol/l) OD (μmol) r=0.402, p=0.003 r=0.299, p=0.033 ID (μmol) r=0.265, p=0.058 r=0.202, p=0.154 WT (μm) r=0.402, p=0.003 r=0.313, p=0.026 WLR r=0.247, p=0.078 r=0.171, p=0.230 WCSA (μm2) r=0.417, p=0.002 r=0.322, p=0.021

Conclusion

With the novel 23Na-MRI technology, we could demonstrate that high tissue sodium concentration is linked to with hypertrophic vascular remodeling of retinal arterioles. Thus, the reduction of tissue sodium content may emerge as a therapeutic target.

Updating genome annotation for the microbial cell factory Aspergillus niger using gene co-expression networks

A significant challenge in our understanding of biological systems is the high number of genes with unknown function in many genomes. The fungal genus Aspergillus contains important pathogens of humans, model organisms, and microbial cell factories. Aspergillus niger is used to produce organic acids, proteins, and is a promising source of new bioactive secondary metabolites. Out of the 14,165 open reading frames predicted in the A. niger genome only 2% have been experimentally verified and over 6,000 are hypothetical. Here, we show that gene co-expression network analysis can be used to overcome this limitation. A meta-analysis of 155 transcriptomics experiments generated co-expression networks for 9,579 genes (∼65%) of the A. niger genome. By populating this dataset with over 1,200 gene functional experiments from the genus Aspergillus and performing gene ontology enrichment, we could infer biological processes for 9,263 of A. niger genes, including 2,970 hypothetical genes. Experimental validation of selected co-expression sub-networks uncovered four transcription factors involved in secondary metabolite synthesis, which were used to activate production of multiple natural products. This study constitutes a significant step towards systems-level understanding of A. niger, and the datasets can be used to fuel discoveries of model systems, fungal pathogens, and biotechnology.

Nonlinear modeling and experimental verification of Gannet-inspired beam systems during diving

A nonlinear model is proposed to answer at which diving speeds and beak angles will cause injury to Gannet-inspired beam systems during plunge-diving. In doing so, the critical velocities at which buckling occurs with various types of boundary conditions are first obtained for vertical dives and the resulting forces at the point of impact are determined. The Gannet-inspired system is modeled as an Euler-Bernoulli beam to represent the neck and body of the Gannet, while the head of the Gannet is modeled as a cone with varying half-angles. The experimental investigations of Gannet-like diving systems are first introduced to present the varying parameters and assumptions of the simplified model. Next, the resulting forces during impact are investigated and a study is conducted to compare various approximations of the drag coefficient for the cone-shaped head. Considering the mid-plane stretching nonlinearity, the equations of motion for the structural system under various types of boundary conditions are derived using the Hamilton's principle. The characteristic equations, buckled configurations, and critical velocities are determined for each set of boundary conditions. The results show that the system with the smallest half-beak angle and thus the lowest drag force and beam length delays the critical velocity and is most representative of a Gannet during diving. The obtained results demonstrate great agreement with the conducted experiments. For clamped-clamped boundary conditions, the critical velocity is found to be the greatest because of the increased stability at both ends of the beam. It is also noted that a nonlinear approximation for the coefficient of drag offers the best fit with the provided experimental values when compared to a hyperbolic tangent approximation, which predicts the coefficient of drag to be less than that obtained in experiments, and thus predicts that the systems will buckle at higher velocities.

[European guidelines for the management of arterial hypertension 2018-what has changed?]

BACKGROUND

In November 2017, the latest American guidelines for the management of arterial hypertension were published. With these guidelines lowering the threshold for hypertension to 130/80 mm Hg, the latest European guidelines were expected with excitement.

OBJECTIVES

This article gives an overview on the European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2018 guidelines for the management of arterial hypertension, thereby identifying the most relevant changes in comparison to previous guidelines.

CURRENT DATA

The latest 2018 ESC/ESH guidelines adhere to the previous definition of hypertension, in which a blood pressure of 140/90 mm Hg is considered as threshold for diagnosis. In contrast, there was a change in blood pressure treatment target from below 140/90 to between 120-129/70-79 mm Hg in patients < 65 years if well tolerated. Among patients ≥ 65 years, a systolic blood pressure between 130 and 139 mm Hg is recommended, whereas a diastolic blood pressure between 70 and 79 mm Hg should be targeted. Additionally the guidelines recommend the use of fixed dose combinations as first choice instead of monotherapy to improve adherence. Interventional treatment strategies should only be applied in carefully selected patients at experienced centers and are not recommended outside of clinical studies and registers. Furthermore, the chapters regarding initiation of blood pressure-lowering therapy and clinical evaluation as well as management of hypertension emergencies have been outlined.

CONCLUSIONS

The latest European guidelines for the management of hypertension include several changes. One of the most important aspects is that-in contrast to the American guidelines-the threshold for diagnosis remains at 140/90 mm Hg, whereas treatment target range has been lowered by roughly 10 mm Hg and single pill fixed dose combinations are recommended.

Early Focal Segmental Glomerulosclerosis as a Cause of Delayed Graft Function With Combined Acute Antibody Rejection: A Case Report

Focal segmental glomerulosclerosis (FSGS) is the most common form of post-transplant glomerulonephritis. We describe a case where a biopsy proved that early recurrence of FSGS on postoperative day 1 was the cause of delayed graft function. A 39-year-old man, on hemodialysis for 15 years due to polycystic kidney disease, received a cadaveric renal transplantation. On postoperative day 1, his hourly urine output decreased from 700-800 mL to 50 mL. The graft biopsy showed a mild acute kidney injury confusing nephrotic syndrome. On postoperative day 45, his creatinine level increased to 3.02 mg/dL with severe proteinuria. A kidney biopsy showed focal segmental glomerulosclerosis. On postoperative day 120, his creatinine level elevated again, concomitant with proteinuria. A kidney biopsy showed FSGS with antibody-mediated rejection. After plasmapheresis, his creatinine level decreased to 1.3 mg/dL with mild proteinuria. Once active in the allograft, de novo FSGS is a potentially aggressive process. In this case, it could be managed because of an accurate diagnosis and appropriate treatment.

Development of the Nutrition and Functionality Assessment (NFA) among Older Adults in Japan

OBJECTIVE

Develop and evaluate the feasibility and validity of the Nutrition and Functionality Assessment (NFA) which identifies "target" older adults who could benefit from a personalized program following evaluation of their nutrition status and physical functionality.

DESIGN

Cross-sectional study.

SETTING

Community and geriatric day-care centers and university in Japan.

PARTICIPANTS

267 older adults aged 65-90.

MEASUREMENTS

The "target" individuals were screened based on gait speed (0.6-1.5 m/s). Nutrition (Mini Nutrition Assessment-short form and protein intake), strength (30s chair sit-to-stand and hand-grip strength) and endurance (6-minute walk) were assessed. Physical activity was monitored using a tri-axil accelerometer for a week. Fried frailty phenotype was also assessed.

RESULTS

Out of 267 individuals, 185 (69%) had gait speed between 0.6-1.5 m/s, corresponding to our "target" group from which, 184 (95%) completed the nutrition and physical functionality assessments with the physical activity monitoring. The NFA was completed in approximately 30 minutes. No adverse events directly due to the NFA were reported. NFA physical functionality and global scores were significantly related to frailty phenotype but nutrition score was not related to frailty phenotype.

CONCLUSION

The study demonstrated that the NFA is a safe and feasible tool to screen target older adults and simultaneously evaluate their nutritional status and physical functionality. Validity of the NFA was partially confirmed by the significant association of the global and physical functionality scores with frailty phenotype. More studies are required to validate and maximize the applicability of the NFA in communities and institutions in Japan and elsewhere.

Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection

BACKGROUND AND PURPOSE

Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular "distal-to-proximal" strategy in the treatment of this stroke subtype in the first large multicentric cohort.

MATERIALS AND METHODS

Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded.

RESULTS

Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months.

CONCLUSIONS

Endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.

Cerebellar Hypoperfusion in Migraine Attack: Incidence and Significance

BACKGROUND AND PURPOSE

Patients diagnosed with migraine with aura have an increased lifetime risk of ischemic stroke. It is not yet clear whether prolonged cortical hypoperfusion during an aura increases the immediate risk of cerebellar infarction because it may induce crossed cerebellar diaschisis and subsequent tissue damage. To address this question, we retrospectively analyzed potential relationships between cortical oligemia and cerebellar hypoperfusion in patients with migraine with aura and their potential relation to small infarct-like cerebellar lesions.

MATERIALS AND METHODS

One hundred six migraineurs who underwent MR imaging, including DSC perfusion, were included in the study. In patients with apparent perfusion asymmetry, we used ROI analysis encompassing 18 infra- and supratentorial ROIs to account for differences in regional cerebral blood flow and volume. The presence of cerebellar hypoperfusion was calculated using an asymmetry index, with values of >10% being considered significant.

RESULTS

We observed perfusion asymmetries in 23/106 patients, 22 in patients with migraine with aura (20.8%). Cerebellar hypoperfusion was observed in 12/23 patients (52.2%), and crossed cerebellar diaschisis, in 9/23 patients (39.1%) with abnormal perfusion. In none of the 106 patients were DWI restrictions observed during migraine with aura.

CONCLUSIONS

Cerebellar hypoperfusion and crossed cerebellar diaschisis are common in patients with migraine with aura and cortical perfusion abnormalities. Crossed cerebellar diaschisis in migraine with aura may be considered a benign phenomenon because we observed no association with DWI restriction or manifest cerebellar infarctions, even in patients with prolonged symptom-related perfusion abnormalities persisting for up to 24 hours.

Zinc Deficiency-Like Syndrome in Fleckvieh Calves: Clinical and Pathological Findings and Differentiation from Bovine Hereditary Zinc Deficiency

Background

Zinc deficiency‐like (ZDL) syndrome is an inherited defect of Fleckvieh calves, with striking similarity to bovine hereditary zinc deficiency (BHZD). However, the causative mutation in a phospholipase D4 encoding gene (PLD4) shows no connection to zinc metabolism.

Objectives

To describe clinical signs, laboratory variables, and pathological findings of ZDL syndrome and their utility to differentiate ZDL from BHZD and infectious diseases with similar phenotype.

Animals

Nine hospitalized calves with crusting dermatitis and confirmed mutation in PLD4 and medical records from 25 calves with crusting dermatitis or suspected zinc deficiency.

Methods

Prospective and retrospective case series.

Results

The 9 calves (age: 5–53 weeks) displayed a moderate to severe crusting dermatitis mainly on the head, ventrum, and joints. Respiratory and digestive tract inflammations were frequently observed. Zinc supplementation did not lead to remission of clinical signs in 4 calves. Laboratory variables revealed slight anemia in 8 calves, hypoalbuminemia in 6 calves, but reduced serum zinc concentrations in only 3 calves. Mucosal erosions/ulcerations were present in 7 calves and thymus atrophy or reduced thymic weights in 8 calves. Histologically, skin lesions were indistinguishable from BHZD. Retrospective analysis of medical records revealed the presence of this phenotype since 1988 and pedigree analysis revealed a common ancestor of several affected calves.

Conclusions and Clinical Importance

ZDL syndrome should be suspected in Fleckvieh calves with crusting dermatitis together with diarrhea or respiratory tract inflammations without response to oral zinc supplementation. Definite diagnosis requires molecular genetic confirmation of the PLD4 mutation.

The long-term relationship between dietary pantothenic acid (vitamin B5) intake and C-reactive protein concentration in adults aged 40 years and older

BACKGROUND AND AIMS

Low-grade inflammation, represented by minor C-reactive protein (CRP) elevation, has a critical role in the early stages of atherosclerosis, and pantothenic acid (PA) may have an antioxidant effect in inflammatory process. However, the long-term relationship between PA intake and CRP has not yet been studied. The objective of the present study was to evaluate the long-term relationship of PA intake to CRP concentration in healthy adults aged 40 years or older living in a rural area of South Korea.

METHODS AND RESULTS

A total of 908 subjects (349 men, 559 women) with repeated data on dietary PA intake and CRP concentration were included in the final analysis. To represent the long-term effect of PA intake, both PA intake at the baseline and average PA intake were used as the exposure, and CRP concentration at the third visit and its change from the baseline to the third visit were used as the outcome. After adjustment for potential confounders, a significant inverse relationship between PA intake and CRP concentration at the third visit was observed (P for trend = 0.001, β = -0.07 (P-value = 0.001) for PA _baseline; P for trend = <0.0001, β = -0.11 (P-value = 0.0004) for PA _{average (baseline, 2nd, 3rd)}). Higher PA intake was significantly related to lower or attenuated increase in CRP concentration (P for trend = 0.002, β = -0.24 (P-value = 0.002) for PA _baseline; P for trend = 0.001, β = -0.35 (P-value = 0.001) for PA _{average (baseline, 2nd, 3rd)}).

CONCLUSIONS

In conclusion, dietary PA intake was inversely related to subsequent CRP concentration in both men and women aged 40 years or older in South Korea.

Fully automated stroke tissue estimation using random forest classifiers (FASTER)

Several clinical trials have recently proven the efficacy of mechanical thrombectomy for treating ischemic stroke, within a six-hour window for therapy. To move beyond treatment windows and toward personalized risk assessment, it is essential to accurately identify the extent of tissue-at-risk ("penumbra"). We introduce a fully automated method to estimate the penumbra volume using multimodal MRI (diffusion-weighted imaging, a T2w- and T1w contrast-enhanced sequence, and dynamic susceptibility contrast perfusion MRI). The method estimates tissue-at-risk by predicting tissue damage in the case of both persistent occlusion and of complete recanalization. When applied to 19 test cases with a thrombolysis in cerebral infarction grading of 1-2a, mean overestimation of final lesion volume was 30 ml, compared with 121 ml for manually corrected thresholding. Predicted tissue-at-risk volume was positively correlated with final lesion volume ( p < 0.05). We conclude that prediction of tissue damage in the event of either persistent occlusion or immediate and complete recanalization, from spatial features derived from MRI, provides a substantial improvement beyond predefined thresholds. It may serve as an alternative method for identifying tissue-at-risk that may aid in treatment selection in ischemic stroke.

Determining the ion temperature and energy distribution in a lithium-plasma interaction test stand with a retarding field energy analyzer

The ThermoElectric-driven Liquid-metal plasma-facing Structures (TELS) experiment at the University of Illinois is a gas-puff driven, theta-pinch plasma source that is used as a test stand for off-normal plasma events incident on materials in the edge and divertor regions of a tokamak. The ion temperatures and resulting energy distributions are crucial for understanding how well a TELS pulse can simulate an extreme event in a larger, magnetic confinement device. A retarding field energy analyzer (RFEA) has been constructed for use with such a transient plasma due to its inexpensive and robust nature. The innovation surrounding the use of a control analyzer in conjunction with an actively sampling analyzer is presented and the conditions of RFEA operation are discussed, with results presented demonstrating successful performance under extreme conditions. Such extreme conditions are defined by heat fluxes on the order of 0.8 GW m^-2 and on time scales of nearly 200 μs. Measurements from the RFEA indicate two primary features for a typical TELS discharge, following closely with the pre-ionizing coaxial gun discharge characteristics. For the case using the pre-ionization pulse (PiP) and the theta pinch, the measured ion signal showed an ion temperature of 23.3 ± 6.6 eV for the first peak and 17.6 ± 1.9 eV for the second peak. For the case using only the PiP, the measured signal showed an ion temperature of 7.9 ± 1.1 eV for the first peak and 6.6 ± 0.8 eV for the second peak. These differences illustrate the effectiveness of the theta pinch for imparting energy on the ions. This information also highlights the importance of TELS as being one of the few linear pulsed plasma sources whereby moderately energetic ions will strike targets without the need for sample biasing.