Adropin as a potential protective factor of metabolic complications in obese pregnant women with hyperglycaemia diagnosed in early pregnancy

Adropin is a hormone which increases insulin sensitivity. It enhances the oxygenation of glucose in the muscles. The 91 obese pregnant women (BMI >30 kg/m²) with gestational diabetes mellitus (GDM) diagnosed in the first half of pregnancy has been recruited to the study group. The control group consisted of 10 age matched and homogeneous pregnant women with BMI <25 kg/m². Blood samples were collected on visit V1 - between the 28^th and 32^nd week and on visit V2 - between the 37^th and 39^th week of gestation. The ELISA test was used to measure the adropin level. The results in the study group and the control group were compared. Blood samples were collected at the same visits. The median concentration of adropin was 442.2 pg/ml on V1 and 453.1 pg/ml on V2. The increase was significant (p<0.05). Results were significantly lower in the control group's patients, i.e. 57.0 pg/ml (p<0.001) on V1 and 107.9 pg/ml on V2 (p<0.001). The higher adropin level on the V1 and V2 visits were related to patients' lower BMI and better metabolic control. The increase in the adropin level in the third trimester may have been involved in the weight gain reduction, whereas better dietary adherence might have had a compensatory effect on increasing insulin resistance. However, the small control group is a limitation of this study.

Adropin as a potential protective factor of metabolic complications in obese pregnant women with hyperglycaemia diagnosed in early pregnancy

Adropin is a hormone which increases insulin sensitivity. It enhances the oxygenation of glucose in the muscles. The 91 obese pregnant women (BMI >30 kg/m²) with gestational diabetes mellitus (GDM) diagnosed in the first half of pregnancy has been recruited to the study group. The control group consisted of 10 age matched and homogeneous pregnant women with BMI <25 kg/m². Blood samples were collected on visit V1 - between the 28^th and 32^nd week and on visit V2 - between the 37^th and 39^th week of gestation. The ELISA test was used to measure the adropin level. The results in the study group and the control group were compared. Blood samples were collected at the same visits. The median concentration of adropin was 442.2 pg/ml on V1 and 453.1 pg/ml on V2. The increase was significant (p<0.05). Results were significantly lower in the control group's patients, i.e. 57.0 pg/ml (p<0.001) on V1 and 107.9 pg/ml on V2 (p<0.001). The higher adropin level on the V1 and V2 visits were related to patients' lower BMI and better metabolic control. The increase in the adropin level in the third trimester may have been involved in the weight gain reduction, whereas better dietary adherence might have had a compensatory effect on increasing insulin resistance. However, the small control group is a limitation of this study.

1028 Early response to a low- dose acubitril/valsartan (ARNI) therapy among stable symptomatic patients with HFrEF

Funding Acknowledgements

no financial support

Background

Sacubitril/valsartan (S/V) has shown to improve outcomes, that is related to reverse remodeling of the left ventricle (LV) with improved ejection fraction (LVEF) and mitral regurgitation (MR) during long-term therapy. There are limited data on early effects of S/V treatment with respect to the left ventricle function and echocardiographic evaluation of this phenomenon.

Aim of the study was to evaluate the early effect of a starting-dose of S/V administered in patients (pts) with stable symptoms of heart failure on clinical symptoms, laboratory tests and echocardiographic parameters using global longitudinal strain (GLS) as a sensitive parameter detecting improvement of LV function.

Methods

Twenty pts (mean age 60 years, 2 female), with HFrEF (NYHA class II-III) on optimal medical treatment with ICM (75%) or NICM (35%) were included to low-dose S/V treatment (24/26mg) after excluding contraindications. Clinical and echocardiographic evaluation was performed at baseline and after 30 days. The following parameters have been measured: 6-Minutes Walking Test (6MWT) and Minnesota Living with Heart Failure questionnaire, laboratory results and echocardiographic assessment with speckle tracking technique (STE).

Results

All pts completed 30 days treatment period without complications and no change to medication. During this period the mean values of RR decreased significantly (SBP 129,4mmHg vs 121,25mmHg and DBP 81,6mmHg vs 79,2mmHg respectively). Other clinical parameters did not change. There were no differences NT-pro BNP and TNT levels (respectively 1726 vs 1930 pg/ml and 26 vs 22 ng/ml). After 30days, the mean 6MWT distance increased by 50m (349,5 vs 401,5m p &lt; 0.01), and a positive response was observed in Minnesota Living with Heart Failure Questionnaire (p &lt; 0.001). Echocardiographic parameters revealed positive remodeling of LV and left atrium (LA). There was a significant improvement in LVEDd (67,9mm vs 64,9mm, p &lt; 0.01), LVESd (61,6mm vs 58,8mm, p &lt; 0.01) and stroke volume (40,5 to 45,8ml, p &lt; 0.01). There was no significant increase in LVEF (30% vs 31,5%, p = 0.052). The diastolic parameters of LV function didn’t change during the study. The LA volumes significantly decreased (110 vs 92ml, p &lt; 0.01) during the treatment period as well as the degree of MR (ERO 0.51 vs 0,37 p &lt; 0.01). Out of several LV deformation parameters, only global longitudinal strain has changed significantly (GLS-6,1% vs -7,0%, p = 0,02). The improvement in symptoms and 6MWT correlated only with global systolic radial (RS) and longitudinal (GLS) strain correlated positively after 30 days treatment. Conclusion:Thirty days treatment with low-dose S/V in stable, symptomatic HFrEF patients leads to symptomatic and clinical improvement which correlates with positive remodeling of the left ventricle and reduces the degree of mitral regurgitation. The GLS is a sensitive indicator of LV function improvement after short time S/V treatment and may be used to assess early response.

P310 The role of the left ventricle deformation parameters determining reverse remodeling due to six months of spironolactone therapy

Introduction

Spironolactone is widely used in the pharmacotherapy of patients (pts) with HFrEF. However, there is still little information on the influence of spironolactone therapy on the global and regional left ventricular (LV) function.

Aim

Evaluation of the influence of regional deformation parameters on global LV systolic function as a result of six months of spironolactone therapy.

Methods

The study included 39 pts (mean age 64 years, with stable heart failure; NYHA class II-III, mean LVEF 37,4%, mean wall motion index score, WMSI 1,62). All pts received optimal standard treatment before entering the study. Then therapy of spironolactone 25mg daily was introduced. Clinical status, treadmill exercise test (compilation time and effort level), NT-pro-BNP and speckle tracking echocardiography (STE) assessment were analyzed. Two groups were created according to LV reverse remodeling (PRR -responders, 10% increase in LVEF and/or 15% decrease in LVESV; NRR- nonresponders). Differences between NRR I PRR, at the start point and after six months therapy of spironolactone for the above-mentioned parameters, were analyzed.

Results

Reverse remodeling was observed in 21 pts (PRR). There were no differences between PRR I NRR in: exercise test on the treadmill (compilation parameters: 27,86 vs 29,41), NYHA class, Nt-pro BNP levels (1071 vs 1172 pg/ml). WMSI in both groups was similar (respectively: 1,62 vs 1,61), however akinetic region in apical and septal regions of LV in NRR were more often represented (NRR 91,6% vs PRR 35% pts). PRR showed significantly better improvement of peak systolic longitudinal (LS) and circumferential (CS) strain in the apical (AP) and LV septal region of LV (SEP) depending on the post-infarction condition. (table 1)

Conclusions

Improvement of left ventricle systolic function depends on the regional contractility status of the myocardium. Longitudinal (LS) and circumferential (CS) peak systolic strain, regardless of ejection fraction and WMSI are the sensitive parameters determining improvements of the LV systolic function. The study showed that cut-off values to predict reverse LV remodeling must be lower than -10.08% for CS and -11.55% for LS.

Tab.1. CS nad LS value at the end point Region of LV NRR mean strain % PRR mean strain% p value (NRRvs PRR) CS AP -11,42 -15,47 0.03 CS SEP -12,3 -17,04 0.02 LV 3CH -13,42 -16,30 0.04 CA AP-circumferential strain in apical LV region, CS SEP- circumferential strain in septal LV region, LV 3CH- longitudinal strain in three-chamber view of LV

[Declared dead? Recommendations regarding integrated care from the perspective of German statutory health insurance]

The traditional separation of health care into sectors in Germany causes communication problems that hinder continuous, patient-oriented care. This is most evident in the transition from inpatient to outpatient care. That said, there are also breaks in the flow of information, a lack of supply, or even incorrect information flowing within same-sector care. The transition from a division of functions into sectors to a patient-oriented process represents a change in the paradigm of health care that can only be successfully completed with considerable effort. Germany's statutory health insurance (SHI) funds play a key role here, as they are the contracting parties as well as the financiers of integrated care, and are strategically located at the center of the development process.The objective of this article is to explore how Germany's SHI funds view integrated care, what they regard as being the drivers of and barriers to transitioning to such a system, and what recommendations they can provide with regard to the further development of integrated care. For this purpose semi-structured interviews with board members and those responsible for implementing integrated care into the operations of ten SHI funds representing more than half of Germany's SHI-insured population were conducted. According to the interviewees, a better framework for integrated care urgently needs to be developed and rendered more receptive to innovation.Only in this way will the widespread stagnation of the past several years be overcome. The deregulation of § 140a-d SGB V and the establishment of a uniform basis for new forms of care in terms of a new innovation clause are among the central recommendations of this article. The German federal government's innovation fund was met with great hope, but also implied risks. Nonetheless, the new law designed to strengthen health care overall generated high expectations.

[Is the needs-based planning mechanism effectively needs-based? An analysis of the regional distribution of outpatient care providers]

AIMS

Since the 1990s licenses for opening a medical practice in Germany are granted based on a needs-based planning system which regulates the regional allocation of physicians in primary care. This study aims at an analysis of the distribution of physicians (and hence the effects of the planning system) with regard to the overarching objective of primary care supply: the safeguarding of "needs-based and evenly distributed health care provision" (Section 70 para 1 German Social Code V).

METHODS

The need for health care provision of each German district (or region) and the actual number of physicians in the respective area are compared using a concentration analysis. For this purpose, the local health-care need was approximated in a model based on the morbidity predictors age and sex and by combining data on the local population structure with the age- and sex-specific frequency of physician consultations (according to data of the GEK sickness fund). The concentration index then measures the degree of regional inequity in the distribution of outpatient care.

RESULTS

The results of the analysis demonstrate an inequitable regional distribution between medical needs of the local population and the existing outpatient health care provider capacities. These regional disparities in needs-adjusted supply densities are particularly large for -outpatient secondary care physicians and psychotherapists, even when taking into account the care provision of urban physicians for peri-urban areas as well as the adequacy of longer travel times to specialists. One major reason for these inequities is the design of today's physician planning mechanism which mainly conserves a suboptimal status quo of the past.

CONCLUSION

The initiated reforms of the planning mechanism should progress and be further deepened. Especially today's quota-based allocation of practice licenses requires fundamental changes taking into account the relevant factors approximating local health care needs, re-assessing the adequate spatial planning level and expanding opportunities for introducing innovative and more flexible health care services models.

Changes of oxidative stress parameters in diabetic pregnancy

BACKGROUND

The molecular aetiology of disturbed embryogenesis and other unfavourable outcomes in offspring of diabetic mothers is not fully understood. Experimental studies have suggested an involvement of radical oxygen species (ROS) in the teratological process.

THE AIM OF OUR STUDY

To investigate if maternal diabetes in humans is capable of inducing alterations in vascular oxidative stress parameters and whether such changes are associated with disturbances in foetal development.

METHODS

Seventy patients with pre-gestational diabetes (PGDM) were chosen for the study: 29 (41.4%) belonged to class B according to White, 15 (21.4%) to class C, 8 (11.4%) to class D, 3 (4.3%) to class F, 3 to class R and 12 (17.1%) to class F/R. In 20 (28.6%) patients from this group an unfavourable outcome was noted. All patients were subjected to intensive insulin therapy. Glycaemia was estimated by daily self-monitoring, and diurnal glucose profiles and glycated haemoglobin (HbA1c) concentrations were measured monthly. Oxidative stress was evaluated as changed superoxide dismutase, catalase and glutathione peroxidase activities as well as of malondialdehyde (MDA) and peroxides concentrations in maternal erythrocytes and blood serum.

RESULTS

Prior to conception, the mean glycaemia in the group that had a planned pregnancy was 6.6mmol/l and HBA1c was 9.35%. Throughout the course of pregnancy, these parameters were maintained at a level of 6.7 mmol/l and 7.85%, respectively. The activity of all antioxidative enzymes was lower before than during pregnancy, and so was the concentration of MDA. The MDA concentrations were higher in patients with elevated glycaemia and with an unfavourable outcome. The investigated ROS, the glycaemia level, as well as the concentration of HBA1c did not show any significant differences between pregnancies with and without vascular complications. Patients with a favourable perinatal outcome presented a higher activity of antioxidant enzymes, than those with unfavourable outcome, throughout the whole course of pregnancy. The appearance of unfavourable perinatal outcomes in relation to parameters of oxidative stress was assessed by logistic regression. Both SOD and GPX activities, as well as peroxides' concentration, showed significant correlations (p < 0.005) with foetal complications. However, after mean glucose levels in the studied group were included into these analyses, this relationship was only evident with SOD and GPX activity (p < 0.0016).

CONCLUSION

Oxidative stress is one of several important factors contributing to unfavourable outcome of human diabetic pregnancy.

[The effect of one-year treatment with captopril on exercise tolerance and myocardial ischemia in patients with myocardial infarction ]

The aim of the study was to assess the effect of 1-year captopril therapy initiated 1-4 days (mean: 21-24 h) after beginning of AMI on exercise performance and myocardial ischemia during cycle ergometer test. 93 pts with first documented Q-wave AMI, aged L 70 years were qualified for the study. 50 of the pts were randomly included to the captopril group, 43 to the control group. In both groups pts with inferior AMI (accordingly 66% and 72%) and normal LV function (EF > or = 40% in ECHO) were prevailed in the study. Captopril therapy was initiated with the dose of 3.125 mg, then every 8 hours the dose of 6.25 mg was administered in Ist and IInd day, 12.5 mg--in III day and 25 mg from IV day on. Exercise cycle ergometer tests (ExT) were performed in every pt at 14 day, and 1, 3, 6 and 12 months after AMI. The ExT began at 25 W of power and was increased at 2-minute intervals by 25 W until fatigue or other typical cause of termination of the test. In the captopril group duration of ExT lengthened significantly in comparison with initial test (on 14 day) after 3 (6.4 +/- 1.47 vs 5.3 +/- 1.54 min; p < 0.01), 6 (6.7 +/- 1.59 vs 5.3 +/- 1.54 min; p < 0.001) and 12 months (7.0 +/- 1.22 vs 5.3 +/- 1.54 min; p < 0.001). In the control group exercise time was longer after 6 and 12 months compared to initial examination (accordingly 6.4 +/- 1.43 and 6.5 +/- 1.26 vs 4.8 +/- 1.47 min; p < 0.001). However, the differences regarding this time between the captopril and control group were not significant on consecutive control stages. The final result of the test (positive, negative, doubtful) did not differ significantly in both groups on consecutive examination stages. Captopril administered during 1-year period after AMI slightly improved physical working capacity (accelerated the improvement) and had no effect on ischemia during estimated cycle ergometer test. These results may depend on inclusion to the study predominantly pts with normal LV function and interior MI.

[Comparative assessment of digoxin and captopril in the treatment of chronic congestive circulatory failure, NYHA grade II]

In 42 patients aged 33 to 79 years (mean age 55 years) with NYHA grade II chronic congestive circulatory failure, a comparative assessment was carried out of the effectiveness of treatment with captopril (29 patients, daily dose 18.75-150 mg, mean 82.5 mg) adn digoxin (13 patients, daily dose 0.125-0.5 mg, mean 0.275 mg). The patients were administered the drugs, depending on the improvement obtained, for 3-5 weeks. In the assessment of the effectiveness of the treatment, the following was taken into account: medical examination, laboratory investigations, chest X-ray, exercise tests and haemodynamic parameters measured during 2D and M echocardiographic examination. In the group of patients treated with digoxin the following was observed: a significant, in comparison to the patients receiving captopril, reduction of the heart rate by 11 beats per minute, decrease of the heart volume index by 50 ml/m2 and increase of the stroke volume by 14 ml. Higher effectiveness of captopril was observed as increase of the maximal workload during exercise test by 21 W and prolongation of its duration by three minutes. It seems that captopril may find use also in the treatment of early stages of circulatory failure.

In vivo effect of 2-deoxy-D-glucose on glucose-6-phosphate dehydrogenase activity in the cytosol of liver, heart and skeletal muscle of rats

2-deoxy-D-glucose (2-DG), the unmetabolizable analogue of glucose induces a series of metabolic, hormonal and behavioral responses, causing cellular glucoprivation. According to in vitro studies, 2-DG inhibits phosphofructokinase in cultured human cells. The present investigations deal with changes in the cytosolic glucose-6-phosphate dehydrogenase activity following in vivo 2-DG administration. A single dose of 2-DG (600 mg/kg) has no influence on the activity of glucose-6-phosphate dehydrogenase in the cytosol of liver, heart and skeletal muscle of the rat. The concomitant increase in serum glucose, lactate and FFA concentrations observed in the study indicates indirectly a stimulation of adrenergic system. After three days of successive administration of 2-DG to rats, dehydrogenase activity decreased in the liver by approx 57% and in the skeletal muscle by approx 82% in comparison with control animals. Moreover the in vivo effect of 2-DG was found to be fully reversible, probably when the total amount of the inhibitor was excreted.