Coronary artery calcium in 2023: Guidelines for LDL-C goals, non-statin therapies, and aspirin use

Personalizing risk assessment and treatment decisions for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) rely on pooled cohort equations and increasingly coronary artery calcium (CAC) score. A growing body of evidence supports that elevated CAC scores correspond to progressively elevated ASCVD risk, and that scores of ≥100, ≥300, and ≥ 1000 denote risk that is equivalent to certain secondary prevention populations. This has led consensus guidelines to incorporate CAC score thresholds for guiding escalation of preventive therapy for lowering low-density lipoprotein cholesterol goals, initiation of non-statin lipid lowering medications, and use of low-dose daily aspirin. As data on CAC continues to grow, more decision pathways will incorporate CAC score cutoffs to guide management of blood pressure and cardiometabolic medications. CAC score is also being used to enrich clinical trial study populations for elevated ASCVD risk, and to screen for subclinical coronary atherosclerosis in patients who received chest imaging for other diagnostic purposes.

Online searches for hepatocellular carcinoma drugs mirror prescription trends across specialties and changes in guideline recommendations

Background & aims

The treatment options for systemically progressed hepatocellular carcinoma (HCC) have significantly expanded in recent years. In this study, we aimed to evaluate the potential of Google searches as a reflection of prescription rates for HCC drugs in the United States (US).

Methods

We conducted an in-depth analysis of US prescription data obtained from the IQVIA National Prescription Audit (NPA) and corresponding Google Trends data from January 2017 to December 2022. We focused on drugs used in the first line and second or later treatment lines for HCC, collecting data on their prescriptions and search rates. Search volumes were collected as aggregated search queries for both generic drugs and their respective brand names.

Results

During the study period from Q1 2017 to Q4 2022, monthly prescriptions for drugs used in HCC treatment showed an 173% increase (from 1253 to 3422). Conversely online searches increased by 3.5% (from 173 to 179 per 10 million searches). Notably, strong correlations were observed between search interest and prescriptions for newer drugs, which indicates increasing usage, while older drugs with declining usage displayed limited correlation. Our findings suggest a growing role of non-physician professions in managing systemically progressed HCC within the US healthcare system, although oncologists remained primarily responsible for drug prescriptions.

Conclusions

In conclusion, online search monitoring can offer the potential to reflect prescription trends specifically related to the treatment of HCC. This approach provides a swift and accessible means of evaluating the evolving landscape of HCC treatment.

LP(a): Structure, Genetics, Associated Cardiovascular Risk, and Emerging Therapeutics

Lipoprotein(a) [Lp(a)] is a molecule bound to apolipoprotein(a) with some similarity to low-density lipoprotein cholesterol (LDL-C), which has been found to be a risk factor for cardiovascular disease (CVD). Lp(a) appears to induce inflammation, atherogenesis, and thrombosis. Approximately 20% of the world's population has increased Lp(a) levels, determined predominantly by genetics. Current clinical practices for the management of dyslipidemia are ineffective in lowering Lp(a) levels. Evolving RNA-based therapeutics, such as the antisense oligonucleotide pelacarsen and small interfering RNA olpasiran, have shown promising results in reducing Lp(a) levels. Phase III pivotal cardiovascular outcome trials [Lp(a)HORIZON and OCEAN(a)] are ongoing to evaluate their efficacy in secondary prevention of major cardiovascular events in patients with elevated Lp(a). The future of cardiovascular residual risk reduction may transition to a personalized approach where further lowering of either LDL-C, triglycerides, or Lp(a) is selected after high-intensity statin therapy based on the individual risk profile and preferences of each patient.

Cardiovascular risk stratification among individuals with obesity: The Coronary Artery Calcium Consortium

OBJECTIVE

The effectiveness of coronary artery calcification (CAC) for risk stratification in obesity, in which imaging is often limited because of a reduced signal to noise ratio, has not been well studied.

METHODS

Data from 9334 participants (mean age: 53.3 ± 9.7 years; 67.9% men) with BMI ≥ 30 kg/m2 from the CAC Consortium, a retrospectively assembled cohort of individuals with no prior cardiovascular diseases (CVD), were used. The predictive value of CAC for all-cause and cause-specific mortality was evaluated using multivariable-adjusted Cox proportional hazards and competing-risks regression.

RESULTS

Mean BMI was 34.5 (SD 4.4) kg/m2 (22.7% Class II and 10.8% Class III obesity), and 5461 (58.5%) had CAC. Compared with CAC = 0, those with CAC = 1-99, 100-299, and ≥300 Agatston units had higher rates (per 1000 person-years) of all-cause (1.97 vs. 3.5 vs. 5.2 vs. 11.3), CVD (0.4 vs. 1.1 vs. 1.5 vs. 4.2), and coronary heart disease (CHD) mortality (0.2 vs. 0.6 vs. 0.6 vs. 2.5), respectively, after mean follow-up of 10.8 ± 3.0 years. After adjusting for traditional cardiovascular risk factors, CAC ≥ 300 was associated with significantly higher risk of all-cause (hazard ratio [HR]: 2.05; 95% CI: 1.49-2.82), CVD (subdistribution HR: 3.48; 95% CI: 1.81-6.70), and CHD mortality (subdistribution HR: 5.44; 95% CI: 2.02-14.66), compared with CAC = 0. When restricting the sample to individuals with BMI ≥ 35 kg/m2 , CAC ≥ 300 remained significantly associated with the highest risk.

CONCLUSIONS

Among individuals with obesity, including moderate-severe obesity, CAC strongly predicts all-cause, CVD, and CHD mortality and may serve as an effective cardiovascular risk stratification tool to prioritize the allocation of therapies for weight management.

Abstract P514: Evaluating the Concordance Between Trends in Prescription Volume and Online Interest for the Weight Loss Formulation of Semaglutide

Introduction: Weight loss dosing of semaglutide (Wegovy™) is a preferred anti-obesity medication due to its efficacy, safety, and potential cardioprotective benefits. However, soon after FDA approval, supply shortages restricted availability and forced the manufacturer to suspend new initiations, despite large interest. We characterized trends in prescription volume of this drug since approval compared to other obesity medications and correlated it to online search interest.

Methods: We derived monthly prescription dispensing and revenue data for all anti-obesity prescription medications from IQVIA’s National Prescription Audit. This audit captures 93% of outpatient prescription dispensing in the U.S. and projects to population-level data. We also retrieved online search data from Google Trends for Health for a variety of terms relevant to obesity treatment and drug generic/brand names. We analyzed data from May 2016 - April 2022 for visual and quantitative trends and assessed correlation between online searches and prescription volume with Spearman's correlation for non-parametric variables.

Results: Prescriptions for Wegovy™ increased rapidly after entering the market in June 2021. It became the second most prescribed weight loss medication within 4 months, below phentermine and ahead of the weight loss dosing of liraglutide (Saxenda™). By December 2021, Wegovy™ comprised 10.7% of weight loss prescriptions. However, in subsequent months, prescriptions plateaued at ≈100,000/month (≈11% market share), coinciding with manufacturer reports of supply shortages. Cardiologists accounted for 0.7% of Wegovy™ use across the study. While the compounded monthly growth rate for prescriptions in the first 5 full months of drug availability was 34%, this slowed to 3% in the final 5 months of the study. Despite slowed growth, Wegovy™ comprised 59% of monthly pharmacy revenue for prescription weight loss drugs ($163 million) by April 2022. An abrupt spike in online searches for “Wegovy,” “semaglutide,” and “weight loss drug” coincided with FDA approval in June 2021, with “Wegovy” searches peaking at 195 queries per 10 million searches before falling to 85 by Sept. 2021. Following this initial peak and fall, Google searches for “Wegovy” rose exponentially, with a monthly increase of 20% in the final 5 months of the study. We observed a weaker correlation between online searches and prescriptions for Wegovy™ (Spearman’s correlation coefficient 0.65) compared with other cardiometabolic drugs which also had growing prescription volumes (0.79-0.99).

Conclusions: As growth in Wegovy™ prescriptions decelerated, online searches continued to grow exponentially, even in the absence of manufacturer marketing. This contrast suggests that interest among clinicians and patients is likely outstripping drug availability, hampering the impending paradigm shift in treatment of obesity.

Association of Different Biochemical and Hemodynamic Characteristic with Type 2 Diabetes Mellitus and Hypertension in Nephrolithiasis Patients

Background Although Nephrolithiasis is a common condition caused by a wide variety of metabolic or environmental disturbances, its being one of the major factor of morbidity. Incidence of kidney stone disease (KSD) is highly affected by metabolic disorders and change in blood pressure and glucose. Objective To find out association of different biochemical and hemodynamic parameters with various glycemic status and hypertension in kidney stone disease. Method A cross sectional study was conducted in patients diagnosed as nephrolithiasis by using re¬nal ultrasonography and underwent nephrectomy between January 2019 to January 2021 in Shahid Dharmabhakta National Transplant Centre (SDNTC). A total of 100 subjects with 60 male and 40 females were enrolled. Glycemic status was categorized based on criteria of American Diabetes Association (ADA) and hypertension was defined as BP ≥ 140/90 mm Hg in right arm supine position. All biochemical and hemodynamic profile was carried out following standard protocol. Result Out of 100 patients enrolled, pre-diabetes accounted for 31% followed by diabetes (4%). However, hypertension comprised of 66% in total subjects. Serum urea, cholesterol and triglyceride level were found to be increased by 84.6%, 67.7% and 64.7% respectively in diabetes followed by increase of 3.9%, 19.5% and 3.1% respectively in prediabetes when compared to normal glycemic condition in nephrolithiasis subjects. Serum fasting blood glucose, creatinine and uric acid level was observed significantly higher (p=0.003, p=0.004, p < 0.001 respectively) in hypertensive patients. Duration of hospital stay was also seen positively correlated with hypertension. Conclusion Not only diabetes, prediabetes also manifests the increased risk of kidney stone disease along with hypertension. There is significant impairment in renal function and lipid profile based on diabetes mellitus and hypertension. Early identifying these systemic diseases, different biochemical and hemodynamic parameters and proper treatment accordingly may minimize risk and prevent serious complication in these patients.

Transitioning to GLP-1 RAs and SGLT2 Inhibitors as the First Choice for Managing Cardiometabolic Risk in Type 2 Diabetes

PURPOSE OF REVIEW

This forward-looking review summarizes existing evidence from cardiovascular outcome trials on cardiometabolic risk-reduction in type 2 diabetes (T2DM) management, with attention to updating and personalizing recommendations from recent diabetes practice guidelines issued by cardiology societies.

RECENT FINDINGS

T2DM management has shifted towards cardiometabolic outcome improvement rather than purely glycemic control. According to large clinical trials, sodium-glucose cotransporter-2 inhibitors showed robust results in reducing heart failure (HF) hospitalization and chronic kidney disease (CKD) progression, while glucagon-like peptide-1 receptor agonists demonstrated the largest effects on HbA1c reduction, weight loss, and atherosclerotic cardiovascular disease outcomes prevention, including stroke. Considering the distinct features of these new cardiometabolic agents, initial selection of therapy should be targeted to each individual patient, with consideration of combination therapy for the highest risk patients. Moreover, future studies should investigate the addition of obesity-predominant risk, in conjunction with coronary artery disease, stroke, CKD, and HF, as a new influential indicator for choosing the optimal cardiometabolic agent.

Understanding the interactive effects of dietary leucine with isoleucine and valine in the modern commercial broiler

A study was conducted to understand the relationship among dietary branched-chain amino acids (BCAA) on the performance of Ross 344 × 708 male broilers. A total of 2,592 d-old male chicks were randomly placed into 144-floor pens according to a 2³ full factorial central composite design (CCD) with 20 treatments (14 treatments and 6 center points). Each treatment consisted of varying digestible Ile:Lys (52 to 75), Val:Lys (64 to 87), and Leu:Lys (110 to 185) ratios. Birds and feed were weighed at 20 and 34 d of age to determine body weight gain (BWG), feed intake, and feed conversion ratio (FCR). At 35 d of age, feather amino acid composition and carcass characteristics were evaluated. Data were analyzed as CCD using the surface response option of JMP v. 15. Body weight gain (1,332 g; P < 0.001; R² = 0.93) and FCR (1.54; P = 0.002; R² = 0.88) were optimized at the lowest Leu:Lys ratio (110) with moderate Val:Lys (78 to 79) and Ile:Lys (65 to 66) ratios. Poorer BWG and FCR were observed as Leu:Lys ratio increased while increasing Val:Lys and Ile:Lys ratios alleviated the poor performance. Carcass (71.5%; P = 0.031; R² = 0.76) and breast yield (26.7%; P < 0.001; R² = 0.96) were maximized at the highest Leu:Lys ratio. This effect was complemented by increasing Ile:Lys ratio beyond 68. Lower Ile:Lys and Val:Lys ratios were required to maximize carcass and breast yield at the lowest Leu:Lys ratio. However, this strategy yielded less meat than providing a high Leu:Lys ratio diet. Dietary BCAA had little effect on altering the composition of feather protein and amino acid (P > 0.10). These results suggest that optimum BCAA ratios to Lys may vary depending on response criteria and demonstrate the importance of maintaining proper Val and Ile ratios centered on dietary Leu. Live performance can be optimized in diets with low Leu:Lys ratios; however, meat yield can be enhanced by increasing dietary Leu:Lys along with Ile:Lys ratios.

Online searches for SGLT-2 inhibitors and GLP-1 receptor agonists correlate with prescription rates in the United States: An infodemiological study

Several clinical trials have demonstrated that many SGLT-2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1 RA) can reduce the risk of cardiovascular events in patients with Type 2 diabetes and atherosclerotic cardiovascular disease. Recent reports indicate an underutilization of new cardiometabolic drugs, including SGLT2i and GLP-1 RA. We aimed to evaluate the use of online search volumes to reflect United States prescription rates. A repeated cross-sectional analysis of Google search volumes and corresponding data from the IQVIA National Prescription Audit (NPA) of pharmacy dispensing of newly prescribed drugs was performed. Monthly data for online searches and prescription between January 1, 2016 and December 31, 2021 were collected for selected SGLT2i and GLP-1 RA. Prescription data for drugs classes (SGLT2i and GLP-1 RA) and individual drugs were calculated as the total of queried data for branded drug names. Trends were analyzed for visual and quantitative correlation as well as predictive patterns. Overall, online searches increased by 157.6% (95% CI: 142.2-173.1%) and 295.2% (95% CI: 257.7-332.6%) for SGLT2i and GLP-1RA between 2016 and 2021. Prescription rates raised by 114.6% (95% CI: 110.8-118.4%) and 221.0% (95% CI: 212.1-229.9%) for SGLT2i and GLP-1RA for this period. Correlation coefficients (range 0.86-0.99) were strongest for drugs with growing number of prescriptions, for example dapagliflozin, empagliflozin, ertugliflozin, dulaglutide, and semaglutide. Online searches might represent an additional tool to monitor the utilization trends of cardiometabolic drugs. Associations were strongest for drugs with reported cardioprotective effect. Thus, trends in online searches complement conventionally acquired data to reflect and forecast prescription trends of cardiometabolic drugs.

National Trends in Use of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists by Cardiologists and Other Specialties, 2015 to 2020

Background

Sodium‐glucose cotransporter‐2 inhibitors (SGLT2is) and glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) mitigate cardiovascular risk in individuals with type 2 diabetes, but most eligible patients do not receive them. We characterized temporal trends in SGLT2i and GLP‐1RA use by cardiologists compared with other groups of clinicians.

Methods and Results

We conducted a descriptive analysis of serial, cross‐sectional data derived from IQVIA’s National Prescription Audit, a comprehensive audit capturing ≈90% of US retail prescription dispensing and projected to population‐level data, to estimate monthly SGLT2is and GLP‐1RAs dispensed from January 2015 to December 2020, stratified by prescriber specialty and molecule. We also used the American Medical Association’s Physician Masterfile to calculate average annual SGLT2is and GLP‐1RAs dispensed per physician. Between January 2015 and December 2020, a total of 63.2 million SGLT2i and 63.4 million GLP‐1RA prescriptions were dispensed in the United States. Monthly prescriptions from cardiologists increased 12‐fold for SGLT2is (from 2228 to 25 815) and 4‐fold for GLP‐1RAs (from 1927 to 6981). Nonetheless, cardiologists represented only 1.5% of SGLT2i prescriptions and 0.4% of GLP‐1RA prescriptions in 2020, while total use was predominated by primary care physicians/internists (57% of 2020 SGLT2is and 52% of GLP‐1RAs). Endocrinologists led in terms of prescriptions dispensed per physician in 2020 (272 SGLT2is and 405 GLP‐1RAs). Cardiologists, but not noncardiologists, increasingly used SGLT2is over GLP‐1RAs, with accelerated uptake of empagliflozin and dapagliflozin coinciding with their landmark cardiovascular outcomes trials and subsequent US Food and Drug Administration label expansions.

Conclusions

While use of SGLT2is and GLP‐1RAs by cardiologists in the United States increased substantially over a 6‐year period, cardiologists still account for a very small proportion of all use, contributing to marked undertreatment of individuals with type 2 diabetes at high cardiovascular risk.

Comparative pathology, molecular pathogenicity, immunological features, and genetic characterization of three highly pathogenic human coronaviruses (MERS-CoV, SARS-CoV, and SARS-CoV-2)

The last two decades have witnessed the emergence of three deadly coronaviruses (CoVs) in humans: severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There are still no reliable and efficient therapeutics to manage the devastating consequences of these CoVs. Of these, SARS-CoV-2, the cause of the currently ongoing coronavirus disease 2019 (COVID-19) pandemic, has posed great global health concerns. The COVID-19 pandemic has resulted in an unprecedented crisis with devastating socio-economic and health impacts worldwide. This highlights the fact that CoVs continue to evolve and have the genetic flexibility to become highly pathogenic in humans and other mammals. SARS-CoV-2 carries a high genetic homology to the previously identified CoV (SARS-CoV), and the immunological and pathogenic characteristics of SARS-CoV-2, SARS-CoV, and MERS contain key similarities and differences that can guide therapy and management. This review presents salient and updated information on comparative pathology, molecular pathogenicity, immunological features, and genetic characterization of SARS-CoV, MERS-CoV, and SARS-CoV-2; this can help in the design of more effective vaccines and therapeutics for countering these pathogenic CoVs.

Efficient Bayesian inference of fully stochastic epidemiological models with applications to COVID-19

Epidemiological forecasts are beset by uncertainties about the underlying epidemiological processes, and the surveillance process through which data are acquired. We present a Bayesian inference methodology that quantifies these uncertainties, for epidemics that are modelled by (possibly) non-stationary, continuous-time, Markov population processes. The efficiency of the method derives from a functional central limit theorem approximation of the likelihood, valid for large populations. We demonstrate the methodology by analysing the early stages of the COVID-19 pandemic in the UK, based on age-structured data for the number of deaths. This includes maximum a posteriori estimates, Markov chain Monte Carlo sampling of the posterior, computation of the model evidence, and the determination of parameter sensitivities via the Fisher information matrix. Our methodology is implemented in PyRoss, an open-source platform for analysis of epidemiological compartment models.

Vascular control of kidney epithelial transporters

A major pathway in hypertension pathogenesis involves direct activation of ANG II type 1 (AT1) receptors in the kidney, stimulating Na+ reabsorption. AT1 receptors in tubular epithelia control expression and stimulation of Na+ transporters and channels. Recently, we found reduced blood pressure and enhanced natriuresis in mice with cell-specific deletion of AT1 receptors in smooth muscle (SMKO mice). Although impaired vasoconstriction and preserved renal blood flow might contribute to exaggerated urinary Na+ excretion in SMKO mice, we considered whether alterations in Na+ transporter expression might also play a role; therefore, we carried out proteomic analysis of key Na+ transporters and associated proteins. Here, we show that levels of Na+-K+-2Cl- cotransporter isoform 2 (NKCC2) and Na+/H+ exchanger isoform 3 (NHE3) are reduced at baseline in SMKO mice, accompanied by attenuated natriuretic and diuretic responses to furosemide. During ANG II hypertension, we found widespread remodeling of transporter expression in wild-type mice with significant increases in the levels of total NaCl cotransporter, phosphorylated NaCl cotransporter (Ser71), and phosphorylated NKCC2, along with the cleaved, activated forms of the α- and γ-epithelial Na+ channel. However, the increases in α- and γ-epithelial Na+ channel with ANG II were substantially attenuated in SMKO mice. This was accompanied by a reduced natriuretic response to amiloride. Thus, enhanced urinary Na+ excretion observed after cell-specific deletion of AT1 receptors from smooth muscle cells is associated with altered Na+ transporter abundance across epithelia in multiple nephron segments. These findings suggest a system of vascular-epithelial in the kidney, modulating the expression of Na+ transporters and contributing to the regulation of pressure natriuresis.NEW & NOTEWORTHY The use of drugs to block the renin-angiotensin system to reduce blood pressure is common. However, the precise mechanism for how these medications control blood pressure is incompletely understood. Here, we show that mice lacking angiotensin receptors specifically in smooth muscle cells lead to alternation in tubular transporter amount and function. Thus, demonstrating the importance of vascular-tubular cross talk in the control of blood pressure.

Low temperature and high magnetic field performance of a commercial piezo-actuator probed via laser interferometry

The advances in the fields of scanning probe microscopy, scanning tunneling spectroscopy, point contact spectroscopy, and point contact Andreev reflection spectroscopy to study the properties of conventional and quantum materials under cryogenic conditions have prompted the development of nanopositioners and nanoscanners with enhanced spatial resolution. Piezoelectric-actuator stacks as nanopositioners with working strokes of 10 μm and positioning resolution ∼(1-10) nm are desirable for both basic research and industrial applications. However, information on the performance of most commercial piezoelectric actuators in cryogenic environment and in the presence of magnetic fields in excess of 5 T is generally not available. In particular, the magnitude, the rate, and the associated hysteresis of the piezo-displacement at cryogenic temperatures are the most relevant parameters that determine whether a particular piezoelectric actuator can be used as a nanopositioner. Here, the design and realization of an experimental setup based on interferometric techniques to characterize a commercial piezoelectric actuator over a temperature range of 2 K ≤ T ≤ 260 K and magnetic fields up to 6 T are presented. The studied piezoelectric actuator has a maximum displacement of 30 μm at room temperature for a maximum driving voltage of 75 V, which reduces to 1.2 μm with an absolute hysteresis of 9.1±3.3nm at T = 2 K. The magnetic field is shown to have no substantial effect on the piezo-properties of the studied piezoelectric-actuator stack.

Controlled Optofluidic Crystallization of Colloids Tethered at Interfaces

We report experiments that show rapid crystallization of colloids tethered to an oil-water interface in response to laser illumination. This light-induced transition is due to a combination of long-ranged thermophoretic pumping and local optical binding. We show that the flow-induced force on the colloids can be described as the gradient of a potential. The nonequilibrium steady state due to local heating thus admits an effective equilibrium description. The optofluidic manipulation explored in this work opens novel ways to manipulate and assemble colloidal particles.

Adherence to Iron, Folic Acid and Calcium Supplement and Factors Affecting it among the Antenatal Care Attending Women in a Tertiary Care Hospital: A Cross Sectional Study

Background Pregnancy or gestation is the time during which a single or more children grows and develops inside a woman. Antenatal care improves the pregnancy outcomes under which a group of medication i.e. iron, folic acid and calcium are supplemented. Despite the effectiveness of such supplements, poor clinical outcomes are often encountered because of poor-adherence to the regimen. Objective To determine the adherence pattern and factors affecting adherence in antenatal care patients under iron, folic acid, and calcium therapy. Method A cross-sectional study was conducted in Dhulikhel Hospital, Kathmandu University Hospital. Pregnant women attending antenatal care under iron, folic acid, and calcium therapy fulfilling the inclusion criteria were enrolled in this study. After obtaining the informed consent from the patients, structured questionnaire was used to interview the patients. Statistical analysis was performed by using SPSS 23.0. P-value < 0.05 was considered as statistically significant. Result Among 191 patients enrolled in this study majority (39.3%) of them belonged to age group 26-30 years. More than half (61.3%) of the patients were illiterate. Of the total 191, 64.40% were non-adherent to the medication. Forgetfulness was the main reason for missing the dose in majority (52.06%) of the non-adherent subjects while adverse effects (55.40%) was the most prominent cause for discontinuing the medication among non-adherent participants. Significant association was found between patients' adherence and busy work schedule, visiting doctor for follow up. Conclusion More than half of the patients had not adhered to the medication under antenatal care. Forgetfulness was the most common factor for missing the dose in nonadherent patients. Illiteracy was associated with poor adherence. Patient-provider relationship, Socio-economic factors were determined as major barrier to medication adherence.

Periodic Orbits of Active Particles Induced by Hydrodynamic Monopoles

Terrestrial experiments on active particles, such as Volvox, involve gravitational forces, torques and accompanying monopolar fluid flows. Taking these into account, we analyze the dynamics of a pair of self-propelling, self-spinning active particles between widely separated parallel planes. Neglecting flow reflected by the planes, the dynamics of orientation and horizontal separation is symplectic, with a Hamiltonian exactly determining limit cycle oscillations. Near the bottom plane, gravitational torque damps and reflected flow excites this oscillator, sustaining a second limit cycle that can be perturbatively related to the first. Our work provides a theory for dancing Volvox and highlights the importance of monopolar flow in active matter.

Effects of additional dosage of vitamin D3, vitamin D2, and 25-hydroxyvitamin D3 on calcium and phosphorus utilization, egg quality and bone mineralization in laying hens

Vitamin D is essential for the metabolism of calcium (Ca) and phosphorus (P) in birds. The objective of the study was to evaluate the effect of different isoforms of dietary vitamin D on Ca and P utilization, egg quality, and bone mineralization of laying hens. A total of 42 Lohmann white laying hens at 57 wk of age were randomly assigned to 7 dietary treatments for 6 wk. Dietary treatments were: 3,000 IU/kg Vit D₃ as control, and control with additional 3,000 IU/kg 25-hydroxyvitamin D₃ (T1), 9,000 IU/kg 25-hydroxyvitamin D₃ (T2), 3,000 IU/kg vitamin D3 (T3), 9,000 IU/kg vitamin D₃ (T4), 3,000 IU/kg of vitamin D₂ (T5), or 9,000 IU/kg of vitamin D₂ (T6). Egg production and egg quality were measured weekly. Fecal samples were collected at weeks 2 and 6 to measure Ca and P utilization. After 6 wk, the left tibia and femurs were collected to measure bone mineral density (BMD) and bone mineral content (BMC). A 1-way ANOVA with Tukey HSD means separation test was used for statistical analysis. There were no significant differences in egg production, egg quality, BMD, or BMC of tibia and femurs among the treatments (P > 0.05). T6 significantly reduced feed intake (P < 0.05). The apparent total tract digestibility (ATTD) of Ca was higher (P < 0.012) in treatments supplemented with additional vitamin D, irrespective of forms. The ATTD of P was higher (P < 0.0001) in T5 compared to the other treatments at both time points. The utilization of Ca and P by laying hens can be improved through the addition of different isoforms of vitamin D in diets. However, additional vitamin D supplementation to laying hens, regardless of forms, had no effect on either bone mineralization or measures of egg quality.

Impact of a multicarbohydrase containing α-galactosidase and xylanase on ileal digestible energy, crude protein digestibility, and ileal amino acid digestibility in broiler chickens

Exogenous enzymatic supplementation of poultry feeds, including α-galactosidase and xylanase, has been shown to increase metabolically available energy, although little information has been published on the impact on amino acid digestibility. An experiment was conducted to investigate a multicarbohydrase containing α-galactosidase and xylanase on amino acid digestibility, ileal digestible energy (IDE), and CP in male broiler chicks. The experiment was a 2 × 2 (diet × enzyme) factorial arrangement with 15 replicates of 8 male broilers per replicate raised for 21 d in a battery setting. The 2 dietary treatments included a positive control (PC) and a negative control (NC) diet formulated to contain 2.5% less calculated AME and digestible amino acids. Each of these diets was fed with and without enzyme. Broilers were fed a starter diet from 0-14 d (crumble) and a grower from 14-21 d (pellet). Birds were sampled on day 21 to determine ileal amino acid digestibility, IDE, and CP digestibility. Titanium dioxide (TiO2) was used as an indigestible marker for the determination of digestibility coefficients. Total ileal amino acid digestibility was increased (P = 0.008) by 3.80% with the inclusion of enzyme. Methionine and lysine digestibility was improved (P < 0.05) with the inclusion of enzyme by 3.37% and 2.61%, respectively. Enzyme inclusion increased (P = 0.001) cysteine digestibility by 9.3%. Diet-influenced ileal amino acid digestibility with tryptophan, threonine, isoleucine, and valine digestibility being increased (P < 0.05) in the PC when compared to the NC. IDE was decreased (P = 0.037) in broilers fed the NC diet by 100 kcal/kg feed when compared to broilers fed the PC diet. Enzyme inclusion increased (P = 0.047) IDE value by 90 kcal/kg. Crude protein digestibility was not influenced by diet; however, similar improvements in CP digestibility with enzyme inclusion were observed as with energy. These data support the benefits of a multicarbohydrase containing α-galactosidase and xylanase inclusion to improve nutrient and ileal amino acid digestibility across multiple dietary nutrient profiles.

Fast Bayesian inference of the multivariate Ornstein-Uhlenbeck process

The multivariate Ornstein-Uhlenbeck process is used in many branches of science and engineering to describe the regression of a system to its stationary mean. Here we present an O(N) Bayesian method to estimate the drift and diffusion matrices of the process from N discrete observations of a sample path. We use exact likelihoods, expressed in terms of four sufficient statistic matrices, to derive explicit maximum a posteriori parameter estimates and their standard errors. We apply the method to the Brownian harmonic oscillator, a bivariate Ornstein-Uhlenbeck process, to jointly estimate its mass, damping, and stiffness and to provide Bayesian estimates of the correlation functions and power spectral densities. We present a Bayesian model comparison procedure, embodying Ockham's razor, to guide a data-driven choice between the Kramers and Smoluchowski limits of the oscillator. These provide novel methods of analyzing the inertial motion of colloidal particles in optical traps.

Redox Reaction Triggered Nanomotors Based on Soft-Oxometalates With High and Sustained Motility

The recent interest in self-propulsion raises an immediate challenge in facile and single-step synthesis of active particles. Here, we address this challenge and synthesize soft oxometalate nanomotors that translate ballistically in water using the energy released in a redox reaction of hydrazine fuel with the soft-oxometalates. Our motors reach a maximum speed of 370 body lengths per second and remain motile over a period of approximately 3 days. We report measurements of the speed of a single motor as a function of the concentration of hydrazine. It is also possible to induce a transition from single-particle translation to collective motility with biomimetic bands simply by tuning the loading of the fuel. We rationalize the results from a physicochemical hydrodynamic theory. Our nanomotors may also be used for transport of catalytic materials in harsh chemical environments that would otherwise passivate the active catalyst.

Influence of Mn co-doping on the magnetic properties of planar arrays of GaxFe4−xN nanocrystals in a GaN matrix

Mn co-doping affects the formation of iron nitride nanocrystals in a GaN matrix, determining the system's structural and magnetic properties.

Direct verification of the fluctuation-dissipation relation in viscously coupled oscillators

The fluctuation-dissipation relation, a central result in nonequilibrium statistical physics, relates equilibrium fluctuations in a system to its linear response to external forces. Here we provide a direct experimental verification of this relation for viscously coupled oscillators, as realized by a pair of optically trapped colloidal particles. A theoretical analysis, in which interactions mediated by slow viscous flow are represented by nonlocal friction tensors, matches experimental results and reveals a frequency maximum in the amplitude of the mutual response which is a sensitive function of the trap stiffnesses and the friction tensors. This allows for its location and width to be tuned and suggests the utility of the trap setup for accurate two-point microrheology.

Colloidal transport by active filaments

Enhanced colloidal transport beyond the limit imposed by diffusion is usually achieved through external fields. Here, we demonstrate the ballistic transport of a colloidal sphere using internal sources of energy provided by an attached active filament. The latter is modeled as a chain of chemo-mechanically active beads connected by potentials that enforce semi-flexibility and self-avoidance. The fluid flow produced by the active beads and the forces they mediate are explicitly taken into account in the overdamped equations of motion describing the colloid-filament assembly. The speed and efficiency of transport depend on the dynamical conformational states of the filament. We characterize these states using filament writhe as an order parameter and identify ones yielding maxima in speed and efficiency of transport. The transport mechanism reported here has a remarkable resemblance to the flagellar propulsion of microorganisms which suggests its utility in biomimetic systems.

Fast Bayesian inference of optical trap stiffness and particle diffusion

Bayesian inference provides a principled way of estimating the parameters of a stochastic process that is observed discretely in time. The overdamped Brownian motion of a particle confined in an optical trap is generally modelled by the Ornstein-Uhlenbeck process and can be observed directly in experiment. Here we present Bayesian methods for inferring the parameters of this process, the trap stiffness and the particle diffusion coefficient, that use exact likelihoods and sufficient statistics to arrive at simple expressions for the maximum a posteriori estimates. This obviates the need for Monte Carlo sampling and yields methods that are both fast and accurate. We apply these to experimental data and demonstrate their advantage over commonly used non-Bayesian fitting methods.

Universal Hydrodynamic Mechanisms for Crystallization in Active Colloidal Suspensions

The lack of detailed balance in active colloidal suspensions allows dissipation to determine stationary states. Here we show that slow viscous flow produced by polar or apolar active colloids near plane walls mediates attractive hydrodynamic forces that drive crystallization. Hydrodynamically mediated torques tend to destabilize the crystal but stability can be regained through critical amounts of bottom heaviness or chiral activity. Numerical simulations show that crystallization is not nucleational, as in equilibrium, but is preceded by a spinodal-like instability. Harmonic excitations of the active crystal relax diffusively but the normal modes are distinct from an equilibrium colloidal crystal. The hydrodynamic mechanisms presented here are universal and rationalize recent experiments on the crystallization of active colloids.

Flow-induced nonequilibrium self-assembly in suspensions of stiff, apolar, active filaments

Active bodies in viscous fluids interact hydrodynamically through self-generated flows. A stiff, apolar, active filament generates symmetric fluid flow around it and thus cannot self-propel. Here we study the mobility and aggregation induced by hydrodynamic flow in a suspension of stiff, apolar, active filaments. We consider two types of active filaments, with those producing extensile or contractile flows along their long axis. Lateral hydrodynamic attractions in extensile filaments lead, independent of the volume fraction, to anisotropic aggregates which translate and rotate ballistically. Lateral hydrodynamic repulsions in contractile filaments lead to microstructured states, where the degree of clustering increases with the volume fraction and the filament motion is always diffusive. Our results demonstrate that the interplay between active hydrodynamic flows and anisotropic excluded volume interactions provides a generic nonequilibrium mechanism for hierarchical self-assembly of active soft matter.

Abstract P269: Sodium Transporter Profile in Mice Lacking AT1A Receptors in the Renal Proximal Tubule

We have reported that mice lacking AT1A receptors (KO) in renal proximal tubule (PT) have 10 mmHg lower baseline BP and less PT fluid reabsorption than wild type (WT). We tested the hypothesis that the lower BP is associated with less abundant renal Na transporters or regulators. Homogenates of renal cortex and medulla (n=6/group) were prepared and 1 and 1/2 protein amounts of each subjected to immunoblot analysis with specific antibodies and quantitated. Results for cortex and medulla, displayed as mean +/- SEM, normalized to mean abundance of WT=1 (*p <0.05), are summarized in figures. In KO vs. WT abundance of PT NHE3, the associated motor myosin VI, the paracellular NaCl transporter claudin 2, and the Na-HCO3 transporter NBCe1 are lower in KO; in the thick ascending limb (TAL) NKCC2 and its associated kinase SPAK are less abundant, and there is a tendency for lower DCT NCC and CCD ENaC in KO. The results support our hypothesis and suggest that KO of PT AT1R reduces transport routes not only in the PT but beyond the PT, in spite of increased volume flow from PT and lower BP.

Abstract P315: Vascular AT1 Angiotensin Receptors Do Not Contribute to Albuminuria or Hyperfiltration in Diabetes

Blockade of the renin angiotensin system (RAS) reduces albuminuria, attenuates hyperfiltration, and slows the progression of diabetic nephropathy (DN) by preventing vasoconstriction and subsequent increases in glomerular hydrostatic pressure. Since RAS blockade disrupts Ang II signaling in all tissues, the specific contribution of vascular actions of AT1 receptors in DN has been difficult to delineate. Therefore, we generated 129 SvEv mice with cell-specific loss of AT1A from VSMCs (SMKOs) using Cre-loxp . To eliminate AT1R from VSMCs, we crossed the SMKO mice with AT1BR -/- mice, lacking the minor AT1B isoform. To study the impact of vascular AT1R in DN, we crossed the AT1B- null SMKOs with mice having the Ins2 C96Y AKITA mutation, which develop DM1 early. To enhance kidney injury, mice underwent uninephrectomy (UNX) at 11wks. Blood glucose levels were elevated (~500mg/dL) and similar at 10, 16 and 24wks between the two groups. Prior to UNX, albuminuria was similar between Control AKITA and AT1B- null SMKO AKITA (62±10 Control AKITA versus 107±27 μg/24hrs SMKO AKITA, P=NS). Albuminuria increased with age in both Control Akita and AT1B- null SMKO AKITA but without significant differences between the groups at 16wks (307±106 vs 313±117 μg/24hrs; P=NS) or 24wks (494±236 versus 730±217 μg/24hrs; P=NS), despite a trend toward higher albuminuria in AT1B- null SMKO AKITAs. There was no significant difference in GFR (using FITC-inulin) between non-diabetic Control and AT1B- null SMKO (15.6±1.2 vs 14.8±0.8 μl/min/g BW), and hyperfiltration was observed in both Control AKITA (23.7±2.4 μl/min/g BW; P=0.003) and AT1B- null SMKO AKITA mice (20.7±1.7 μl/min/g BW; P=0.01) relative to their non-diabetic comparators. However, there was no significant difference in GFR between ControlAKITA and AT1B- null SMKO AKITA (P=NS). Finally we measured mRNA levels of putative kidney injury markers by RTqPCR and found no differences in levels of Col1A1 , NGAL , or TGFB1 mRNA between Control AKITA and AT1B null SMKO AKITA. Our studies indicate that the absence of vascular AT1R responses is not sufficient to reduce albuminuria and prevent hyperfiltration in a mouse model of DN. This suggests that blockade of AT1R in other cell lineages may contribute to beneficial actions of ARBs in DN.

Brownian microhydrodynamics of active filaments

Slender bodies capable of spontaneous motion in the absence of external actuation in an otherwise quiescent fluid are common in biological, physical and technological contexts. The interplay between the spontaneous fluid flow, Brownian motion, and the elasticity of the body presents a challenging fluid-structure interaction problem. Here, we model this problem by approximating the slender body as an elastic filament that can impose non-equilibrium velocities or stresses at the fluid-structure interface. We derive equations of motion for such an active filament by enforcing momentum conservation in the fluid-structure interaction and assuming slow viscous flow in the fluid. The fluid-structure interaction is obtained, to any desired degree of accuracy, through the solution of an integral equation. A simplified form of the equations of motion, which allows for efficient numerical solutions, is obtained by applying the Kirkwood-Riseman superposition approximation to the integral equation. We use this form of equation of motion to study dynamical steady states in free and hinged minimally active filaments. Our model provides the foundation to study collective phenomena in momentum-conserving, Brownian, active filament suspensions.

Acute Disseminated Encephalomyelitis Following Typhoid Fever: A Case Report

The involvement of central nervous system in children with typhoid fever is common. Acute disseminated encephalomyelitis is a rare immune mediated and demyelinating disease of the central nervous system that usually affects children. We report a 7-year-old child with typhoid fever who developed acute cerebellar syndrome due to acute disseminated encephalomyelitis.Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 55-58 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10237

Irreducible representations of oscillatory and swirling flows in active soft matter

Recent experiments imaging fluid flow around swimming microorganisms have revealed complex time-dependent velocity fields that differ qualitatively from the stresslet flow commonly employed in theoretical descriptions of active matter. Here we obtain the most general flow around a finite sized active particle by expanding the surface stress in irreducible Cartesian tensors. This expansion, whose first term is the stresslet, must include, respectively, third-rank polar and axial tensors to minimally capture crucial features of the active oscillatory flow around translating Chlamydomonas and the active swirling flow around rotating Volvox. The representation provides explicit expressions for the irreducible symmetric, antisymmetric, and isotropic parts of the continuum active stress. Antisymmetric active stresses do not conserve orbital angular momentum and our work thus shows that spin angular momentum is necessary to restore angular momentum conservation in continuum hydrodynamic descriptions of active soft matter.

Physicochemical and functional characteristics of lentil starch

The physicochemical properties of lentil starch were measured and linked up with its functional properties and compared with those of corn and potato starches. The amylose content of lentil starch was the highest among these starches. The crystallinity and gelatinization enthalpy of lentil starch were the lowest among these starches. The high amylose: amylopectin ratio in lentil starch resulted into low crystallinity and gelatinization enthalpy. Gelatinization and pasting temperatures of lentil starch were in between those of corn and potato starches. Lentil starch gels showed the highest storage modulus, gel strength and pasting viscosity than corn and potato starch gels. Peleg's model was able to predict the stress relaxation data of these starches well (R(2)>0.98). The elastic modulus of lentil starch gel was less frequency dependent and higher in magnitude at high temperature (60 °C) than at lower temperature (10 °C). Lentil starch is suitable where higher gel strengthened pasting viscosity are desired.

Autonomous motility of active filaments due to spontaneous flow-symmetry breaking

We simulate the nonlocal Stokesian hydrodynamics of an elastic filament which is active due a permanent distribution of stresslets along its contour. A bending instability of an initially straight filament spontaneously breaks flow symmetry and leads to autonomous filament motion which, depending on conformational symmetry, can be translational or rotational. At high ratios of activity to elasticity, the linear instability develops into nonlinear fluctuating states with large amplitude deformations. The dynamics of these states can be qualitatively understood as a superposition of translational and rotational motion associated with filament conformational modes of opposite symmetry. Our results can be tested in molecular-motor filament mixtures, synthetic chains of autocatalytic particles, or other linearly connected systems where chemical energy is converted to mechanical energy in a fluid environment.