Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Helium line ratio imaging in the C-2W divertor

A 2D imaging instrument has been designed and deployed on C-2W ("Norman") [H. Gota et al., Nucl. Fusion 61, 106039 (2021)] to study the plasma in the expander divertor by simultaneously measuring three neutral helium spectral lines. Ratios of these images, in conjunction with a collisional-radiative model, yield 2D maps of electron temperature and density. Almost the entire radial plasma cross-section (∼60 cm) can be mapped with a spatial resolution ≲1 cm. These data can, in principle, be acquired at 3 kHz. The neutral helium target is provided by a custom-built supersonic gas injector located inside the divertor vessel, which injects helium toward the magnetic axis and perpendicular to the camera sight-cone. Images of helium emission and reconstructed electron density and temperature profiles of the plasma produced from an end gun are presented. Voltages applied to concentric annular electrodes located in the divertors are used to stabilize beam-driven field reversed configuration plasmas. Magnetic field expansion is also employed to thermally isolate electrons from the end electrodes. Measurements of electron temperature and density in the divertor are important in order to study the effects of both the electrostatic biasing and the divertor magnetic field on electron confinement, neutral gas transport, and the overall machine performance.

Wire calorimeter for direct neutral beam power measurements on C-2W

The C-2W experiment produces advanced beam-driven field reversed configuration (FRC) plasmas, which are sustained in steady state utilizing variable energy neutral beams (15-40 keV, total power up to 21 MW), advanced divertors, end bias electrodes, and an active plasma control system. Since heating, current drive, and refueling from neutral beam injection are essential to FRC sustainment, it is crucial to have accurate measurements of the beam power being injected into the plasma. A new tungsten wire calorimeter has been designed, built, calibrated on a test stand, and implemented to make the first direct measurements of the time-average injected beam power into C-2W. This paper outlines the design of the diagnostic, along with calibration methods and experimental results.

The impact of COVID-19 upon student radiographers and clinical training

Introduction

To investigate student clinical placement concerns and opinions, during the initial COVID-19 pandemic outbreak and to inform educational institution support planning.

Methods

Between mid-June to mid-July 2020, educational institutions from 12 countries were invited to participate in an online survey designed to gain student radiographer opinion from a wide geographical spread and countries with varying levels of COVID-19 cases.

Results

1277 respondents participated, of these 592 had completed clinical placements during January to June 2020. Accommodation and cohabiting risks were identified as challenging, as was isolation from family, travel to clinical placements, and to a lesser extent childcare. Students stated they had been affected by the feeling of isolation and concerns about the virus whilst on placement. Overall 35.4% of all respondents were ‘Not at all worried’ about being a radiographer, however, 64.6% expressed varying levels of concern and individual domestic or health situations significantly impacted responses (p ≤ 0.05). Year 4 students and recent graduates were significantly more likely to be ‘Not worried at all’ compared to Year 2 and 3 students (p ≤ 0.05). The need for improved communication regarding clinical placements scheduling was identified as almost 50% of students on clinical placements between January to June 2020 identified the completion of assessments as challenging. Furthermore, only 66% of respondents with COVID-19 imaging experience stated being confident with personal protective equipment (PPE) use.

Conclusion

Student radiographers identified key challenges which require consideration to ensure appropriate measures are in place to support their ongoing needs. Importantly PPE training is required before placement regardless of prior COVID-19 imaging experience.

Implications for practice

As the next academic year commences, the study findings identify important matters to be considered by education institutions with responsibility for Radiography training and as students commence clinical placements during the on-going global COVID-19 pandemic.

OP0035 EXAMINATION OF INTERSTITIAL LUNG DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS – PREVALENCE, TIME TO ONSET, AND CLINICAL CHARACTERISTICS

Background:

Interstitial lung disease (ILD) is a known extraarticular manifestation of rheumatoid arthritis (RA). Previous studies have shown variability in the prevalence of RA-ILD, as well as clinical characteristics and risk factors of RA-ILD.

Objectives:

To evaluate the prevalence and time to onset of ILD and compare the clinical characteristics between RA patients (pts) with or without ILD using a large US electronic medical record (EMR)-based dataset.

Methods:

Pts with an initial RA diagnosis (ICD-9-CM code: 714.0; ICD-10-CM codes: M05 & M06) during the study period (01JAN2009-20SEP2019) were included from the Discus Analytics JointMan database. The initial RA diagnosis date was defined as the index date. Pts with ILD were identified by ICD diagnosis codes or by provider indication in the JointMan record. Pts who developed ILD before RA were excluded from this analysis. The prevalence and time to onset of ILD were reported. Pt demographics, comorbidities, RA characteristics and disease activity scores were compared for 6 months prior to or on the index date (baseline period) for selected adult RA pts with available information.

Results:

Among 8,963 identified RA pts, 337 (3.8%) were diagnosed with ILD on or after RA diagnosis. The median time to ILD onset post-RA was 2.3 years, and 47% had ILD within 2 years after RA diagnosis. RA-ILD pts were significantly older than those without ILD (65.8 years vs. 59.1 years; p<0.001; Table 1). At baseline, a higher percentage of RA-ILD pts had history of chronic obstructive pulmonary disease, positive rheumatoid factor, rheumatoid nodules, erosive joint disease, positive anti-cyclic citrullinated peptide antibody, and joint swelling compared to RA-only pts (Table 2). The mean ESR and RA disease activity scores were also significantly higher for RA-ILD pts.

Table 1.

Patient Demographics

Patient demographicsRA-ONLY COhort(N = 5,612)RA-ild coHORT(N = 205)P-valueAge, Mean ± SD, years59.1 ± 14.265.8 ± 11.8<.001Male, N (%)1,375 (24.5%)72 (35.1%)0.001Race, N (%) White4,014 (71.5%)165 (80.5%)0.005 African American365 (6.5%)9 (4.4%)0.226 Other/Missing1,233 (22.0%)31 (15.1%)0.020Table 2.

Baseline Clinical Characteristics

Clinical CharacteristicsRA-ONLY COhort(N = 3,846)RA-ild coHORT(N = 115)P-valueHistory of Chronic Obstructive Pulmonary Disease, N (%)102 (2.7%)8 (7.0%)0.006Hypertension, N (%)900 (23.4%)23 (20.0%)0.395Serious Infection, N (%)38 (1.0%)3 (2.6%)0.091Rheumatoid Factor Positive, N (%)1,388 (36.1%)69 (60.0%)<.001Joint Stiffness, N (%)1,092 (28.4%)39 (33.9%)0.197Rheumatoid Nodules, N (%)153 (4.0%)17 (14.8%)<.001Erosive Joint Disease, N (%)459 (11.9%)23 (20.0%)0.009Anti-CCP Antibody Positive, N (%)858 (22.3%)45 (39.1%)<.001Joint Swelling*, N (%)2,861 (58.0%)123 (68.0%)0.008Joint Tenderness*, N (%)3,728 (75.6%)138 (76.2%)0.851ESR**, Mean ± SD, mm/hr22.0 ± 22.630.1 ± 25.5<.001CRP**, Mean ± SD, mg/L22.5 ± 13.060.6 ± 25.00.086CDAI, Mean ± SD16.4 ± 12.318.9 ± 15.70.044DAS28-CRP, Mean ± SD2.6 ± 1.23.1 ± 1.4<.001DAS28-ESR, Mean ± SD3.3 ± 1.43.9 ± 1.5<.001SDAI, Mean ± SD20.2 ± 29.328.6 ± 40.20.048

* A total of 4,929 non-ILD and 181 ILD patients had joint swelling and tenderness data.

** Variables were calculated among patients who had available information.

Conclusion:

This large real-world RA population provides insight into the burden of ILD in RA pts. Pts with ILD had a higher proportion of comorbidities and RA-related conditions and higher RA activity. Further analysis is warranted to assess the risk factors of ILD and its prognosis.

Disclosure of Interests:

Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Qisu Zhang Consultant of: I am a paid employee of STATinMED Research which is a paid consultant to Bristol-Myers Squibb Company., Keith Knapp Consultant of: In the last year, I was a paid consultant to Bristol Myers-Squibb Company., Employee of: I am a paid employee of Discus Analytics., Yuexi Wang Consultant of: I am a paid employee of STATinMED Research which is a paid consultant to Bristol-Myers Squibb Company., Cynthia Gutierrez Consultant of: I am a paid employee of STATinMED Research which is a paid consultant to Bristol-Myers Squibb Company., Ding He Consultant of: I am a paid employee of STATinMED Research which is a paid consultant to Bristol-Myers Squibb Company., Lin Xie Consultant of: I am a paid employee of STATinMED Research which is a paid consultant to Bristol-Myers Squibb Company., Sonie Lama Shareholder of: I own shares of Bristol-Myers Squibb Company., Employee of: I am a paid employee of Bristol-Myers Squibb Company., Gary Craig Consultant of: I have served as a consultant to Bristol-Myers Squibb Company., Employee of: I am a paid employee of Arthritis Northwest and VP of Discus Analytics., Speakers bureau: I am a member of the speakers bureau for Bristol-Myers Squibb Company.

Design of a custom insertable probe platform for measurements of C-2W inner divertor plasma parameters

A custom motor controlled probe system has been designed to make spatially resolved measurements of temperature, density, flow, and plasma potential in the C-2W inner divertors. Measurements in the inner divertors, which have a 1.7 m radius and are located on either end of the confinement vessel, are critical in order to gauge exactly how local settings affect the plasma conditions, confinement, and stability in the field-reversed configuration core. The inner Divertor Insertable Probe Platform (iDIPP) system consists of a custom motor controlled linear rack and pinion transporter that has a 1.9 m travel length in order to reach the center of the divertor. Mounted to the end of the transporter is a 1 m long segmented probe shaft made of individually floating stainless steel rings to prevent shorting out the electrode plates, which are biased up to 5 kV/m. A variety of interchangeable probe tips, including a triple Langmuir probe, a baffled probe, and a Gundestrup probe, can plug into the end of the probe shaft. Custom UHV coiled cabling comprised of 9 shielded conductors expands/retracts with the motion of the transporter in/out of the divertor. The physics motivating plasma parameter measurements in the inner divertors and the details of the design of the iDIPP system will be discussed.

Magnetic diagnostic suite of the C-2W field-reversed configuration experiment

A fundamental component of any magnetically confined fusion experiment is a firm understanding of the magnetic field. The increased complexity of the C-2W machine warrants an equally enhanced diagnostic capability. C-2W is outfitted with over 700 magnetic field probes of various types. They are both internal and external to the vacuum vessel. Inside, a linear array of innovative in-vacuum annular flux loop/B-dot combination probes provide information about plasma shape, size, pressure, energy, temperature, and trapped flux when coupled with established theoretical interpretations. A linear array of B-dot probes complement the azimuthally averaged measurements. A Mirnov array of 64 3D probes, with both low and high frequency resolution, detail plasma motion and MHD modal content via singular value decomposition analysis. Internal Rogowski probes measure axial currents flowing in the plasma jet. Outside, every feed-through for an internal probe has an external axial field probe. There are many external loops that measure the plasma formation dynamics and the total external magnetic flux. The external measurements are primarily used to characterize eddy currents in the vessel during a plasma shot. Details of these probes and the data derived from their signals are described.

Particle and heat flux diagnostics on the C-2W divertor electrodes

A suite of diagnostics was developed to measure particle and heat fluxes arriving at the divertor electrodes of the C-2W experiment at TAE Technologies. The divertor electrodes consist of 4 concentric rings, each equipped with a bolometer, electrostatic energy analyzer, and thermocouple mounted at two opposing azimuthal locations. These probes provide measurements of the power flux to the divertor electrodes as well as measurements of the ion current density, ion energy distribution, and total energy deposition. The thermocouples also provide calibration points for inferring the heat deposition profile via thermographic imaging of the electrodes with a fast infrared camera. The combined measurements enable the calculation of the energy lost per escaping electron/ion pair, which is an important metric for understanding electron heat transport in the open field lines that surround the field-reversed configuration plasma in C-2W.

Studies on Thalidomide as a Cause of Congenital Malformations

In 1961 an increase in certain congenital malformations was noticed in various parts of the Federal Republic of Germany. From the outset, it seemed very probable that a single cause was responsible, since, although these malformations varied, they appeared to belong to one and the same syndrome. For general reasons, such causes as radioactivity, contraceptives, attempted abortions or virus diseases did not provide an acceptable explanation. The epidemiology was, however, suggestive of some chemical substance taken orally.

After thalidomide had been indicated in several histories, suspicion of that drug was aroused and, within one week, intake of it could be proved or was found to be very likely in 17 out of 20 cases, while in the remaining cases it could not be excluded. Though this first result was highly significant, we were at first reluctant to incriminate thalidomide definitely, because there was still some doubt about the reliability of the histories. But within a few weeks, the thalidomide aetiology received support from many sources. Specific studies on limited material are sometimes superior to extensive, broadly planned investigations.

Untersuchungen über Contergan in der Ätiologie der Mißbildungen2

Im Jahre 1961 fiel eine Zunahme bestimmter Mißbildungen an mehreren Orten der Bundesrepublik auf. Da es sich um ein zwar variables aber doch einheitliches Syndrom zu handeln schien, das offenbar um das Vielfache der früheren Häufigkeit ähnlicher Fälle zugenommen hatte, war von vornherein mit großer Wahrscheinlichkeit anzunehmen, daß nur eine einzige Ursache verantwortlich sein könne. Verschiedene denkbare Ursachen, wie radioaktive Strahlen, empfängnisverhütende Mittel, Abtreibungsversuche oder Viruserkrankungen mußten aufgrund allgemeiner Überlegungen als sehr unwahrscheinlich angesehen werden. Die epidemiologische Situation ließ in erster Linie einen oral aufgenommenen chemischen Stoff vermuten. Nachdem in anamnestischen Angaben mehrfach Thalidomid aufgetaucht war, Heß sich im Laufe einer Woche bei 17 von 20 Fällen die Einnahme von Thalidomid sichern oder sehr wahrscheinlich machen, in den restlichen Fällen aber nicht ausschließen. Obwohl dieses erste Ergebnis eine sehr hohe statistische Signifikanz hatte, beurteilten wir es zunächst noch zurückhaltend, weil gewisse Zweifel bezüglich der Vergleichbarkeit der Kontrollanamnesen bestanden. In wenigen Wochen ergaben sich dann zahlreiche voneinander unabhängige Bestätigungen der Thalidomid-ätiologie. Unter gewissen Umständen können gezielte Untersuchungen an kleinem Material großen ungezielten Erhebungen überlegen sein.

A Review on Bone Mineral Density Loss in Total Knee Replacements Leading to Increased Fracture Risk

The link between low bone mineral density (BMD) scores leading to greater fracture risk is well established in the literature; what is not fully understood is the impact of total knee replacements/revisions or arthroplasties on BMD levels. This literature review attempts to answer this question. Several different databases using specific key terms were searched, with additional papers retrieved via bibliographic review. Based on the available evidence, total knee replacements/revisions and arthroplasties lower BMD and thus increase fracture risk. This review also addresses the possible implications of this research and possible options to reduce this risk.

Fast imaging diagnostics on the C-2U advanced beam-driven field-reversed configuration device

The C-2U device employed neutral beam injection, end-biasing, and various particle fueling techniques to sustain a Field-Reversed Configuration (FRC) plasma. As part of the diagnostic suite, two fast imaging instruments with radial and nearly axial plasma views were developed using a common camera platform. To achieve the necessary viewing geometry, imaging lenses were mounted behind re-entrant viewports attached to welded bellows. During gettering, the vacuum optics were retracted and isolated behind a gate valve permitting their removal if cleaning was necessary. The axial view incorporated a stainless-steel mirror in a protective cap assembly attached to the vacuum-side of the viewport. For each system, a custom lens-based, high-throughput optical periscope was designed to relay the plasma image about half a meter to a high-speed camera. Each instrument also contained a remote-controlled filter wheel, set between shots to isolate a particular hydrogen or impurity emission line. The design of the camera platform, imaging performance, and sample data for each view is presented.

Clonal B cells in Waldenström's macroglobulinemia exhibit functional features of chronic active B-cell receptor signaling

Waldenström's macroglobulinemia (WM) is a B-cell non-Hodgkin's lymphoma (B-NHL) characterized by immunoglobulin M (IgM) monoclonal gammopathy and the medullary expansion of clonal lymphoplasmacytic cells. Neoplastic transformation has been partially attributed to hyperactive MYD88 signaling, secondary to the MYD88 L265P mutation, occurring in the majority of WM patients. Nevertheless, the presence of chronic active B-cell receptor (BCR) signaling, a feature of multiple IgM+ B-NHL, remains a subject of speculation in WM. Here, we interrogated the BCR signaling capacity of primary WM cells by utilizing multiparametric phosphoflow cytometry and found heightened basal phosphorylation of BCR-related signaling proteins, and augmented phosphoresponses on surface IgM (sIgM) crosslinking, compared with normal B cells. In support of those findings we observed high sIgM expression and loss of phosphatase activity in WM cells, which could both lead to signaling potentiation in clonal cells. Finally, led by the high-signaling heterogeneity among WM samples, we generated patient-specific phosphosignatures, which subclassified patients into a ‘high' and a ‘healthy-like' signaling group, with the second corresponding to patients with a more indolent clinical phenotype. These findings support the presence of chronic active BCR signaling in WM while providing a link between differential BCR signaling utilization and distinct clinical WM subgroups.

Far infrared laser polarimetry and far forward scattering diagnostics for the C-2 field reversed configuration plasmas

A two-chord far infrared (FIR) laser polarimeter for high speed sub-degree Faraday rotation measurements in the C-2 field reversed configuration experiment is described. It is based on high power proprietary FIR lasers with line width of about 330 Hz. The exceptionally low intrinsic instrument phase error is characterized with figures of merit. Significant toroidal magnetic field with rich dynamics is observed. Simultaneously obtained density fluctuation spectra by far forward scattering are presented.

Langmuir probe diagnostic suite in the C-2 field-reversed configuration

Several in situ probes have been designed and implemented into the diagnostic array of the C-2 field-reversed configuration (FRC) at Tri Alpha Energy [M. Tuszewski et al. (the TAE Team), Phys. Rev. Lett. 108, 255008 (2012)]. The probes are all variations on the traditional Langmuir probe. They include linear arrays of triple probes, linear arrays of single-tipped swept probes, a multi-faced Gundestrup probe, and an ion-sensitive probe. The probes vary from 5 to 7 mm diameter in size to minimize plasma perturbations. They also have boron nitride outer casings that prevent unwanted electrical breakdown and reduce the introduction of impurities. The probes are mounted on motorized linear-actuators allowing for programmatic scans of the various plasma parameters over the course of several shots. Each probe has a custom set of electronics that allows for measurement of the desired signals. High frequency ( > 5MHz) analog optical-isolators ensure that plasma parameters can be measured at sub-microsecond time scales while providing electrical isolation between machine and data acquisition systems. With these probes time-resolved plasma parameters (temperature, density, spatial potential, flow, and electric field) can be directly/locally measured in the FRC jet and edge/scrape-off layer.

Fusion proton diagnostic for the C-2 field reversed configuration

Measurements of the flux of fusion products from high temperature plasmas provide valuable insights into the ion energy distribution, as the fusion reaction rate is a very sensitive function of ion energy. In C-2, where field reversed configuration plasmas are formed by the collision of two compact toroids and partially sustained by high power neutral beam injection [M. Binderbauer et al., Phys. Rev. Lett. 105, 045003 (2010); M. Tuszewski et al., Phys. Rev. Lett. 108, 255008 (2012)], measurements of DD fusion neutron flux are used to diagnose ion temperature and study fast ion confinement and dynamics. In this paper, we will describe the development of a new 3 MeV proton detector that will complement existing neutron detectors. The detector is a large area (50 cm(2)), partially depleted, ion implanted silicon diode operated in a pulse counting regime. While the scintillator-based neutron detectors allow for high time resolution measurements (∼100 kHz), they have no spatial or energy resolution. The proton detector will provide 10 cm spatial resolution, allowing us to determine if the axial distribution of fast ions is consistent with classical fast ion theory or whether anomalous scattering mechanisms are active. We will describe in detail the diagnostic design and present initial data from a neutral beam test chamber.

Combining metabolomic analysis and microarray gene expression analysis in the characterization of the medicinal plant Chelidonium majus L

BACKGROUND AND OBJECTIVE

Even though herbal medicines have played an important role in disease management and health for many centuries, their present frequent use is challenged by the necessity to determine their complex composition and their multitarget mode of action. In the present study, modern methods were investigated towards their potential in the characterization of herbal substances. As a model the herbal substance Chelidonii herba was used, for which several reports on liver toxicities exist. Extracts of Chelidonii herba with different solvents were characterized phytochemically and functionally by experiments with HepG2 liver cells.

METHODS

Chelidonii herba was extracted with four solvents of different polarity (dichloromethane, water, ethanol, and ethanol 50% (V/V); four replicates each). The different extracts were characterized metabolomically by (1)H-NMR fingerprinting analysis and principal component analysis (PCA). The content of alkaloids was additionally determined by RP-HPLC. Functional characterization was achieved by the determination of cell proliferation and by transcriptomics techniques (Whole Genome Gene Expression Microarrays v2, Agilent Technologies) in HepG2 cells after exposure to the different extracts (four experimental replicates each).

RESULTS

Based on data from (1)H-NMR fingerprints and RP-HPLC analyses the different extracts showed a divergent composition of constituents depending on the solvent used. HepG2 liver cells responded differentially to the four extracts. Microarray analysis revealed a significant regulation of genes and signal cascades related to biotransformation. Also liver-toxic signal cascades were activated. Neither the activated genes nor the proliferation response could be clearly related to the differing alkaloid content of the extracts.

CONCLUSION

Different manufacturing processes lead to different herbal preparations. A systems biology approach combining a metabolomic plant analysis with a functional characterization by gene expression profiling in HepG2 cells is an appropriate strategy to characterize variations in plant extracts. Safety assessments of herbal substances may benefit from such complementary analyses.

Magnetic diagnostic suite of the C-2 field-reversed configuration experiment confinement vessel

Magnetic measurements are a fundamental part of determining the size and shape of field-reversed configuration (FRC) plasmas in the C-2 device. The magnetic probe suite consists of 44 in-vessel and ex-vessel probes constructed using various technologies: ultra-high vacuum compatible mineral-insulated cable, nested triple axis coils hand-wound on ceramic bobbins, and commercial chip inductors mounted on printed circuit boards. Together, these probes measure the three-dimensional excluded flux profile of the FRC, which approximates the shape of the separatrix between the confined plasma volume and the scrape-off layer. High accuracy is achieved by using the extensive probe measurements to compensate for non-ideal effects such as flux leakage through the vacuum vessel and bulk motion of the FRC towards the wall. A subset of the probes is also used as a set of Mirnov arrays that provide sensitive detection of perturbations and oscillations of the FRC.

Internal magnetic field measurement on C-2 field-reversed configuration plasmas

A long-lived field-reversed configuration (FRC) plasma has been produced in the C-2 device by dynamically colliding and merging two oppositely directed, highly supersonic compact toroids (CTs). The reversed-field structure of the translated CTs and final merged-FRC state have been directly verified by probing the internal magnetic field structure using a multi-channel magnetic probe array near the midplane of the C-2 confinement chamber. Each of the two translated CTs exhibits significant toroidal fields (B(t)) with opposite helicity, and a relatively large B(t) remains inside the separatrix after merging.

A photodiode-based neutral particle bolometer for characterizing charge-exchanged fast-ion behavior

A neutral particle bolometer (NPB) has been designed and implemented on Tri Alpha Energy's C-2 device in order to spatially and temporally resolve the charge-exchange losses of fast-ion populations originating from neutral beam injection into field-reversed configuration plasmas. This instrument employs a silicon photodiode as the detection device with an integrated tungsten filter coating to reduce sensitivity to light radiation. Here we discuss the technical aspects and calibration of the NPB, and report typical NPB measurement results of wall recycling effects on fast-ion losses.

Measurements of neutral density profiles using a deuterium Balmer-alpha diagnostic in the C-2 FRC plasma

In C-2 field-reversed configuration (FRC) device, low neutral density outside the FRC separatrix is required to minimize the charge exchange loss of fast particles. Titanium gettering is used in C-2 to reduce the wall recycling and keep the neutral density low in plasma edge. The measurements of neutral density radial profile are desirable to understand the plasma recycling and the effects of titanium gettering. These measurements are also needed to study the interaction of neutral beams with FRC plasma and confinement of fast ions. Diagnostic based on absolute deuterium Balmer-alpha (D-alpha) radiation measurements is developed and deployed on C-2 device to measure the radial profile of neutral density. Simultaneous measurements of electron density and temperature are done using CO(2) interferometer, Thomson scattering, and triple probes diagnostics along with absolute D-alpha radiation. Abel inversion was performed to get the time dependent radial profile of the local D-alpha emission density. Neutral density profiles are obtained under different machine conditions of titanium deposition.

Field reversed configuration confinement enhancement through edge biasing and neutral beam injection

Field reversed configurations (FRCs) with high confinement are obtained in the C-2 device by combining plasma gun edge biasing and neutral beam injection. The plasma gun creates an inward radial electric field that counters the usual FRC spin-up. The n = 2 rotational instability is stabilized without applying quadrupole magnetic fields. The FRCs are nearly axisymmetric, which enables fast ion confinement. The plasma gun also produces E × B shear in the FRC edge layer, which may explain the observed improved particle transport. The FRC confinement times are improved by factors 2 to 4, and the plasma lifetimes are extended from 1 to up to 4 ms.

Doppler spectroscopy and D-alpha emission diagnostics for the C-2 FRC plasma

Two Doppler spectroscopy diagnostics with complementary capabilities are developed to measure the ion temperatures and velocities of FRC plasmas in the C-2 device. First, the multichord ion doppler diagnostic can simultaneously measure 15 chords of the plasma using an image intensified camera. Second, a single-chord fast-response ion Doppler diagnostic provides much higher faster time response by using a 16-channel photo-multiplier tube array. To study the neutral density of deuterium under different wall and plasma conditions, a highly sensitive eight-channel D-alpha diagnostic has been developed and calibrated for absolute radiance measurements. These spectroscopic diagnostics capabilities, combined with other plasma diagnostics, are helping to understand and improve the field reversed configuration plasmas in the C-2 device.

Two-chord interferometry using 3.39 μm He-Ne laser on a flux-coil-generated FRC

A two-chord λ(IR)∼3.39 μm He-Ne laser interferometer system was developed for a flux-coil-generated field-reversed configuration to estimate the electron density and the total temperature of the field-reversed configuration (FRC) plasma. This two-chord heterodyne interferometer system consists of a single ∼2 mW infrared He-Ne laser, a visible (λ(vis)∼632.8 nm) He-Ne laser for the alignment, a 40 MHz acousto-optic modulator, photodetectors, and quadrature phase detectors. Initial measurement was performed and the measured average electron densities were 2-10×10(19) m(-3) at two different radial positions in the midplane. A time shift in density was observed as the FRC expands radially. The time evolution of the line-averaged density agrees with the density estimated from the in situ internal magnetic probes, based on a rigid-rotor profile model.

Dynamic formation of a hot field reversed configuration with improved confinement by supersonic merging of two colliding high-β compact toroids

A hot stable field-reversed configuration (FRC) has been produced in the C-2 experiment by colliding and merging two high-β plasmoids preformed by the dynamic version of field-reversed θ-pinch technology. The merging process exhibits the highest poloidal flux amplification obtained in a magnetic confinement system (over tenfold increase). Most of the kinetic energy is converted into thermal energy with total temperature (T{i}+T{e}) exceeding 0.5 keV. The final FRC state exhibits a record FRC lifetime with flux confinement approaching classical values. These findings should have significant implications for fusion research and the physics of magnetic reconnection.

Autologous transplantation of CD133 selected hematopoietic progenitor cells for treatment of relapsed acute lymphoblastic leukemia

A 21-year-old white male with relapsed acute lymphoblastic leukemia (ALL) developed an invasive Zygomycosis infection 3 weeks after beginning re-induction chemotherapy. Because of the high risk of fatal recurrence of the fungal infection, neither long-term maintenance chemotherapy nor allogeneic hematopoietic stem cell transplant (HSCT) was considered appropriate. Because his ALL blasts expressed CD34 but lacked CD133, he received a CD133 selected autologous graft following high-dose consolidation chemotherapy. The patient survives in remission 19 months after HSCT.

Sensitivity to mechanical stimuli and the role of general sensory and perceptual processes in heartbeat detection

Sensitivity to heartbeat sensations is commonly assessed using tasks that require individuals to judge the simultaneity of heartbeats and tones. In two experiments, we investigated the suitability of this paradigm for examining cardioception. In the first experiment, participants judged the simultaneity of near-threshold vibrations and suprathreshold tones. Precision in judging vibration-tone simultaneity was directly related to the detectability of the mechanical stimuli, thereby supporting use of the simultaneity paradigm to assess heartbeat detection. In the second experiment, we examined the influences of sensitivity to mechanical stimuli and the ability to make intermodality simultaneity judgments on the precision of heartbeat detection. We measured participants' vibrotactile thresholds, precision in judging light-tone simultaneity, and precision in judging heartbeat-tone simultaneity. The ability to judge the simultaneity of lights and tones accounted for 24.3% of the variance in precision of heartbeat detection, and mechanical sensitivity accounted for a further 8.5%.

Revascularization of femoral head ischemic necrosis with vascularized bone graft: a CT scan experimental study

An ischemic necrosis of the femoral head was induced in 15 mongrel adult dogs using the technique described by Gartsman et al. [10]. Five weeks later, a free vascularized rib graft was transferred into the previously induced ischemic femoral head. High resolution computed tomographic scanning was used to evaluate revascularization 4, 8 and 12 weeks after grafting. The femoral head exhibited new vessel formation throughout the study. Arterial terminal branches arising from the rib graft medullary and periosteal circulations extended beyond the rib graft, entered the head, and reached the subchondral plate. Even where the rib graft did not replenish the central core of the head, there was vascular supply from the grafted bone's vascular tree. These results suggest that a free vascularized bone graft is able to revascularize an experimentally induced ischemic femoral head necrosis.

Vascular medullary patency in free vascularized bone grafts: CT scan experimental study

In an experimental study using 13 mongrel adult dogs, 6 cm of the anterior part of the left ninth rib were harvested, including the posterior intercostal vessels. The grafts were transferred, based on the periosteal circulation alone, to a previously induced femoral head ischemic necrosis. Microsurgical anastomoses were performed between the posterior intercostal vascular bundle and the caudal gluteal vessels at the recipient thigh zone. Using a high resolution CT scan and morphologic evaluation, it was demonstrated that the medullary circulation network filled on contrast medium. The entire cortex and medullary cavity were supplied from endosteal vessels coming from a reversed periosteal blood flow.

Giant pacemaker spikes. An electrocardiographic artifact

The size and orientation of the spikes produced by a pacemaker are often used by clinicians as an index of the pacemaker's function. Following implantation, the pacemaker spikes ordinarily remain constant in size; alterations suggest electrical or mechanical malfunction. We describe a patient in whom giant spikes from a pacemaker were recorded on a digital electrocardiograph shortly after implantation. An electrocardiogram taken the following day, using an analog machine, showed marked diminution in the pacemaker spike. Because of a different type of signal processing, digital electrocardiographs show much larger spikes from pacemakers than do analog machines.

Effects of toxicosis on the predatory behavior of the golden hamster (Mesocricetus auratus)

The purpose of this study was to measure the effects that toxicosis had on the hamster's predatory behavior and to compare these results with those found in previous studies with grasshopper mice. A 0.15 M LiCl injection caused hamsters to develop a greater aversion and to inhibit their feeding and attack responses more frequently toward a house cricket than did a similar injection of NaCl. The added presence of an almond coating on the cricket prolonged the number of days that a hamster exhibited an aversion toward the prey and an inhibition to attack. Essentially, the inhibitory effects from toxicosis in the hamster paralleled those found with the grasshopper mouse. The differences in these inhibitory effects are attributed to inherent differences in the attack responses of the two rodents.

[Influence of atrial contraction on stroke volume in pacemaker stimulation]

The contribution of the atrial systole to the stroke volume was studied in 12 patients with implanted pacemakers by means of impedance-cardiography. P-ST-intervals between 70 and 200 msec. increased the stroke volume as compared with systoles without preceding P-waves. A maximal stroke volume was observed with a P-ST-interval of 130 msec. The increase of the stroke volume by 33% justifies the application of atrial triggered pacemakers in selected cases, mainly in younger patients despite of the technical limitations of these pacemaker systems.