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.

A new method for phosphate purification for oxygen isotope ratio analysis in freshwater and soil extracts using solid-phase extraction with zirconium-loaded resin

RATIONALE

Phosphate (PO₄ ) oxygen isotope (δ¹⁸ O_PO4 ) analysis is increasingly applied to elucidate phosphorus cycling. Due to its usefulness, analytical methods continue to be developed and improved to increase processing efficiency and applicability to various sample types. A new pretreatment procedure to obtain clean Ag₃ PO₄ using solid-phase extraction (SPE) with zirconium-loaded resin (ZrME), which can selectively adsorb PO₄ , is presented and evaluated here.

METHODS

Our method comprises (1) PO₄ concentration, (2) PO₄ separation by SPE, (3) cation removal, (4) Cl^- removal, and (5) formation of Ag₃ PO₄ . The method was tested by comparing the resulting δ¹⁸ O_PO4 of KH₂ PO₄ reagent, soil extracts (NaHCO₃ , NaOH, and HCl), freshwater, and seawater with data obtained using a conventional pretreatment method.

RESULTS

PO₄ recovery of our method ranged from 79.2% to 97.8% for KH₂ PO₄ , soil extracts, and freshwater. Although the recovery rate indicated incomplete desorption of PO₄ from the ZrME columns, our method produced high-purity Ag₃ PO₄ and accurate δ¹⁸ O_PO4 values (i.e., consistent with those obtained using conventional pretreatment methods). However, for seawater, the PO₄ recovery was low (1.1%), probably due to the high concentrations of F^- and SO₄ ^2- which interfere with PO₄ adsorption on the columns. Experiments indicate that the ZrME columns could be regenerated and used repeatedly at least three times.

CONCLUSIONS

We demonstrated the utility of ZrME for purification of PO₄ from freshwater and soil extracts for δ¹⁸ O_PO4 analysis. Multiple samples could be processed in three days using this method, increasing sample throughput and potentially facilitating more widespread use of δ¹⁸ O_PO4 analysis to deepen our understanding of phosphorus cycling in natural environments.

P-384 Efficacy of endometrial microbiome metagenomic analysis with recurrent implantation failure and recurrent pregnancy loss: multicenter study in Japan

Study question

Does the result of endometrial microbiome metagenomic analysis (EMMA), a next generation sequencing (NGS)-based test of the intrauterine microbiome, have an impact on pregnancy rate after the test?

Summary answer

After recommend treatment with antimicrobial and probiotic therapy, the group diagnosed as dysbiosis by EMMA achieved pregnancy significantly earlier than the group with Normal result.

What is known already

Using NGS technology, EMMA testing can determine the composition of the endometrial microbiome by analysing bacterial 16S ribosomal RNA with a focus on the lactobacillus population. Endometrial flora in patients undergoing in vitro fertilization (IVF) is often composed of pathogenic microorganisms which decrease implantation rates, such as the Enterobacteriaceae family, Staphylococcus spp., Escherichia coli and Gram-negative bacteria. Other studies also indicate that Lactobacillus spp. is a major microorganism in the endometrium. Especially, lactobacillus-dominated microbiota (LDM, defined as &gt; 90% Lactobacillus spp.) in the endometrium has been reported to lead to better pregnancy outcomes than non-LDM (&lt;90% Lactobacillus spp.).

Study design, size, duration

This study was a prospective, multicenter cohort study of 527 patients (under 42 years old) with recurrent implantation failure (RIF) and recurrent pregnancy loss (RPL) at 14 IVF treatment facilities in Japan from June 2019 to August 2021. Defining RIF as three or more failed implantation attempts and RPL as two or more miscarriages, we examined the prognosis of two additional embryo transfers (ETs) after the EMMA test in patients who underwent the test.

Participants/materials, setting, methods

Endometrial tissue was obtained by aspiration from patients in day 15-25 of their menstrual cycles, and sample tissues were analyzed by NGS for EMMA. Participant centers treated patients according to the therapies specified in the reports, including antibiotic treatments, probiotic treatments, re-analysis, and embryo transfer. Multivariate analysis was performed using a generalized linear model with the endpoint of ongoing pregnancy. For the time-to-event analyses, we used Kaplan-Meier survival analysis to compare time to ongoing pregnancy.

Main results and the role of chance

The results of the first EMMA were as follows: 229 patients (43.4%) were normal with Lactobacillus spp. &gt;90% (Normal group), 110 patients (20.9%) were abnormal with less than 90% Lactobacillus spp. and predominantly pathogenic bacteria (Abnormal group), and 188 patients (35.7%) were mild with low absolute amounts of bacteria and ultralow biomass indicating almost sterile (Mild + Ultralow group). There were no significant differences in background factors such as age, duration of infertility, number of previous ETs, or history of deliveries among the three groups. Gardnerella was the most pathogenic bacteria detected in patients with Abnormal EMMA results. All patients in the Abnormal group were treated with antimicrobials and probiotics, and those in Mild + Ultralow group were treated with probiotics. Odds ratio for ongoing pregnancy rate was 1.10(95%CI 0.67-1.82, p = 0.699) in Abnormal group and 1.23(95%CI 0.80-1.89, p = 0.342) in Mild + Ultralow group, respectively. After the intervention, ongoing pregnancies were comparable to those in Normal group.Analysis of time to pregnancy using Kaplan-Meier survival curves showed that Abnormal group had a significantly higher rate of ongoing pregnancies during the observation period than the other groups (p = 0.031).

Limitations, reasons for caution

Since this study was not necessarily limited to euploid embryos transferred after testing, an aging bias cannot be excluded. Since this study was conducted with all patients receiving EMMA, the effectiveness of the test needs to be further validated by comparison to patients without EMMA testing.

Wider implications of the findings

This study is the first multicenter study to demonstrate that the intervention based on EMMA reports improve pregnancy outcome in the patients with RIF and RPL. We suggest that the EMMA procedure, which aims at establishing an appropriate uterine microbiome, may be important for implantation and pregnancy continuation.

Trial registration number

UMIN000036917

P–763 Neonatal outcomes of the first 65 infants delivered after IVF treatment with progestin-primed ovarian stimulation using dienogest in patients with endometriosis

Study question

What is the perinatal outcome of pregnancies resulting from a controlled ovarian hyperstimulation (COH) regimen of progestin-primed ovarian stimulation (PPOS) protocol using dienogest (DNG) in patients with endometriosis?

Summary answer

No difference in mean birth weight, however preterm and low birth weight babies are significantly more in the group treated with PPOS using DNG.

What is known already

Dienogest is an oral progestin effective for the treatment of endometriosis, such as reduction of endometrial lesion and control of pain intensity with safety profile and good tolerability. We reported for the first time in the world that DNG was better than dydrogesterone (DYG) for PPOS in terms of the mature oocytes rate and the fertilization rate in patients with endometriosis. Although there have been several reports of infants born with PPOS using DYG, it is essential to report on the perinatal outcome of embryos transferred after treatment with PPOS using DNG from now on. Study design, size, duration: We prospectively investigated the perinatal outcomes of 65 newborns which were the result of using a new COH regimen; PPOS with DNG. The results were compared with perinatal outcome data of babies born between 2018 and 2020 to 815 patients who underwent assisted reproductive technology (ART) treatment at our fertility center. As for the congenital malformation rate, the data was also compared with the 2017 Japanese data bank of babies born after ART treatment.

Participants/materials, setting, methods

We studied the perinatal data of all babies born after transfer of frozen embryos acquired by COH using PPOS protocol with DNG. The rate of maternal complications during pregnancy, pregnancy duration, birth weight, congenital malformations and method of delivery were investigated. We compared the perinatal outcomes of infants born after in vitro fertilization (IVF) and frozen embryo transfer at our center during the same period.

Main results and the role of chance

Perinatal data of 65 babies (study group) were compared with the perinatal data of 840 babies born after IVF at our center, and 47807 babies born after ART in Japan, 2017. We found 3 twin and 59 singleton pregnancies in the study group, compared to 23 twins, 1 triplet and 791 singleton pregnancies during the same period at our center. Considering singletons, there was no difference in mean birthweight (study group; 2893.2±652g vs. total at our center; 3001.2±425g, respectively, p = 0.102). Preterm births (&lt;37 weeks) were significantly more frequent in the PPOS using DNG treatment group than in total at our center (19.2% vs. 9.7%, p = 0.016). The percentage of infants with a birth weight &lt; 2.5 kg was also significantly higher in the PPOS treatment group compared to the total at our center (22.6% vs.11.9%, p = 0.015). The Caesarean section rate was 53.2% in the study group vs. 47.1% control group of our center respectively (p = 0.353). One babies in the study group had malformations in the ocular region. There was no significant difference in congenital malformations between the study group and ART data bank in Japan, 2017 (OR 0.67, 95% CI 0.093: 4.836).

Limitations, reasons for caution

The number of babies is still low, further prospective studies including larger populations are needed to confirm the efficacy of PPOS protocol with DNG.

Wider implications of the findings: This is the first report on the perinatal outcome of babies born by a new COH method using PPOS with DNG, which is a combination of endometriosis treatment and COH for IVF. The association of endometriosis with preterm birth and low birth weight needs to be further investigated.

Trial registration number

UMIN000031111

Sensitive Gas Chromatography Detection of Nanomolar Hydroxylamine in Environmental Water by Fe(III) Oxidation

Nanomolar concentrations of NH₂OH in natural water sources were determined using an Fe³⁺ oxidation method. A pH of 2.35 - 2.50 was used, which was adjusted by adding a chloroacetate buffer. Equal amounts (1.0 mL) of the chloroacetate solution and ferric chloride solution were added to the water sample (70 mL) to oxidize NH₂OH to N₂O. The resulting N₂O in the sample water was then quantified by headspace analysis using a gas chromatograph with an electron-capture detector (ECD), where a limit of detection of 0.2 μgN L^-1 (14 nmol L^-1) was achieved. This method was successfully applied to samples of freshwater, brackish water, and seawater, and despite the various salinities no interfering substances were observed. Furthermore, NH₂OH was successfully detected in samples collected from the Hii River and Lakes Shinji and Nakaumi (Shimane Prefecture, Japan). In addition, the proposed method was also applicable to samples rich in organic substance derived from phytoplankton.

A multi-centre, retrospective case series of oocyte cryopreservation in unmarried women diagnosed with haematological malignancies

STUDY QUESTION

Is oocyte cryopreservation an applicable option for fertility preservation in unmarried patients with haematological malignancies?

SUMMARY ANSWER

Oocyte cryopreservation via the vitrification method is accessible and may be considered an option for fertility preservation in unmarried patients with haematological malignancies.

WHAT IS KNOWN ALREADY

Haematological malignancies are most commonly observed amongst adolescent and young adult women. Although the survival rate and life expectancy of those with haematological malignancies have improved, chemotherapy and radiotherapy may impair their reproductive potential. Oocyte cryopreservation is thus an ideal option to preserve their fertility.

STUDY DESIGN SIZE DURATION

This study retrospectively evaluated 193 unmarried patients (age: 26.2 ± 0.4 years) with haematological malignancies, who consulted for oocyte cryopreservation across 20 different fertility centres in Japan between February 2007 and January 2015. The primary outcome measures were the oocyte retrievals and oocyte cryopreservation outcomes. The secondary outcome measures were the outcomes following oocyte warming for IVF.

PARTICIPANTS/MATERIALS SETTING METHODS

The patients had commenced ovarian stimulation cycles via antagonist, agonist, natural and minimal methods for oocyte retrievals, defined according to the treatment strategy of each respective fertility centre. A vitrification method using the Cryotop safety kit was used for oocyte cryopreservation. ICSIs were used for insemination of warmed oocytes. The endometrial preparation method for embryo transfer was hormonal replacement therapy, except in the case of a patient who underwent a spontaneous ovulatory cycle.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 193 patients, acute myeloid leukaemia (n = 45, 23.3%) was most common, followed by acute lymphoid leukaemia (n = 38, 19.7%) and Hodgkin's lymphoma (n = 30, 15.5%). In total, 162 patients (83.9%) underwent oocyte retrieval, and oocytes were successfully cryopreserved for 155 patients (80.3%). The mean number of oocyte retrieval cycles and cryopreserved oocytes were 1.7 ± 0.2 and 6.3 ± 0.4, respectively. As of December 2019, 14 patients (9.2%) had requested oocyte warming for IVF. The survival rate of oocytes after vitrification-warming was 85.2% (75/88). The rates of fertilisation and embryo development were 80.0% (60/75) and 46.7% (28/60), respectively. Ten patients (71.4%) had successful embryo transfers, and seven live births (50.0%) were achieved.

LIMITATIONS REASONS FOR CAUTION

This study was limited by its retrospective nature. Additionally, there remains an insufficient number of cases regarding the warming of vitrified oocytes to reliably conclude whether oocyte cryopreservation is effective for patients with haematological malignancies. Further long-term follow-up study is required.

WIDER IMPLICATIONS OF THE FINDINGS

Oocyte retrieval and oocyte cryopreservation were accessible for patients with haematological malignancies; however, the number of oocyte retrievals may have been limited due to the initiation of cancer treatments. Acceptable embryonic and pregnancy outcomes could be achieved following oocyte warming; therefore, our results suggest that oocyte cryopreservation can be considered an option for fertility preservation in patients with haematological malignancies.

STUDY FUNDING/COMPETING INTERESTS

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Comparison between optical frequency domain imaging and intravascular ultrasound in PCI guidance for Biolimus A9 eluting stent implantation

Background

It has been reported that intravascular ultrasound (IVUS) guided PCI reduced a risk of major adverse cardiac event compared to conventional angiography guided PCI, while comparison between IVUS-guided and optical frequency domain imaging (OFDI)-guided PCI specifically in long-term clinical outcomes (&gt;1 year) has been unexplored.

Purpose

We sought to compare imaging surrogates at 8 months and clinical outcomes beyond 1 year after drug-eluting stent implantation between IVUS and OFDI guidance.

Methods

The MISTIC-1 is a prospective, multi-centre, single-blinded, randomised-controlled, non-inferiority trial comparing OFDI-guided and IVUS-guided PCI using Biolimus A9 eluting Nobori stent. We enrolled patients with stable coronary artery disease who have symptoms or clinically relevant myocardial ischemia. Stent landing zones were selected in the most normal looking sites with largest lumen and without percentage plaque area &gt;50% in IVUS group while without lipidic plaque of &gt;2 quadrants or suggestive thin-cap fibroatheroma in OFDI group. Stent sizing was based on external elastic lamina (EEL) in IVUS group, while by taking 10% or 0.25mm larger than mean lumen diameter at reference sites in OFDI group. Stent optimisation with in-stent minimum lumen area ≥80% of the average lumen area at proximal and distal reference sites was encouraged in both groups. Primary efficacy endpoint is in-segment minimum lumen area (MLA) assessed by OFDI at 8 months. Secondary safety endpoint is a composite of cardiovascular death, target vessel myocardial infarction, or target lesion revascularisation. Based on the assumption that mean in-segment MLA at follow-up was 4.5mm2 with a standard deviation of 2.0mm2 in the control (IVUS) group and a non-inferiority limit of 1.2mm2 for OFDI group, sample size was estimated as 48 cases in each group with 5% type I error and 90% statistical power.

Results

Since June-2014 and August-2016, we prospectively enrolled 109 patients (mean age 70 years, male 78%) with 126 lesions. Baseline patient and lesion characteristics were well balanced and average nominal size and length of stent used did not differ between OFDI-guided and IVUS-guided PCI (3.0 and 19.1mm vs. 3.1 and 19.3mm, respectively). Post-procedural minimum stent area was 6.24mm2 in OFDI group and 6.72mm2 in IVUS group (p=0.20). At 8-month follow-up, in-segment MLA was 4.56mm2 in OFDI group and 4.13mm2 in IVUS group (P for non-inferiority &lt;0.001). During the follow-up (median 4.5 years [1654 days]), incidence rates of major adverse cardiac event were comparable between the two groups (7.4% in OFDI group and 7.3% in IVUS group, hazard ratio 0.96, 95% CI 0.24–3.83, p=0.95). No definite or probable stent thrombosis were documented in both groups.

Conclusion

OFDI-guided PCI demonstrated comparable results in achieving satisfactory imaging surrogates as well as long-term clinical outcomes after newer generation DES implantation as compared to IVUS-guided PCI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Suzuken Memorial Foundation

Neonicotinoids disrupt aquatic food webs and decrease fishery yields

Invertebrate declines are widespread in terrestrial ecosystems, and pesticide use is often cited as a causal factor. Here, we report that aquatic systems are threatened by the high toxicity and persistence of neonicotinoid insecticides. These effects cascade to higher trophic levels by altering food web structure and dynamics, affecting higher-level consumers. Using data on zooplankton, water quality, and annual fishery yields of eel and smelt, we show that neonicotinoid application to watersheds since 1993 coincided with an 83% decrease in average zooplankton biomass in spring, causing the smelt harvest to collapse from 240 to 22 tons in Lake Shinji, Shimane Prefecture, Japan. This disruption likely also occurs elsewhere, as neonicotinoids are currently the most widely used class of insecticides globally.

6108Efficacy of the PCSK9 inhibitor for lipid-rich coronary plaque reduction: a near-infrared spectroscopy analysis

Background

Recently, some studies have highlighted proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors produce incremental low-density lipoprotein cholesterol (LDL-C) lowering effect. However, it is unknown whether the lipid composition of plaque changes is associated with serum LDL-C reduction due to PCSK9 inhibitors administration.

Purpose

The purpose of this study was to determine the effects of PCSK9 inhibitor (PCSK9i) on coronary plaque component in patients with a history of coronary artery disease (CAD) assessed by near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS).

Methods

A total of 67 non-culprit coronary segments were identified in 34 patients. These lesions were analyzed utilizing NIRS-IVUS at baseline and follow-up coronary angiography (CAG). The subjects were divided into two groups according to lipid-lowering treatment; administration of PCSK9i group (PCSK9i: 19 segments, 9 patients) and traditional statin treatment group (Control: 48 segments, 25 patients). The change of lipid-rich plaque distribution between baseline and follow-up NIRS-IVUS was defined as the change of maximal lipid core burden index (LCBI) score for each of the 4-mm longitudinal segments (maxLCBI4mm).

Results

Mean duration from baseline to follow-up CAG was 239.4±52.4 days in the PCSK9i group and 341.0±84.1 days in the Control group (p<0.001). Despite the higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) in the PCSK9i group at baseline (206.6±40.9 mg/dl vs. 168.5±37.1 mg/dl, 131.5±35.4 mg/dl vs. 100.0±29.5 mg/dl; respectively, p<0.001 for both), the PCSK9i group was significantly lower TC and LDL-C at the follow-up (111.5±23.5 mg/dl vs. 157.4±27.8 mg/dl, 40.8±15.7 mg/dl vs. 86.2±19.6 mg/dl; respectively, p<0.001 for both). Furthermore, the PCSK9i group induced greater regression of maxLCBI4mm than that of Control group (99.6±156.6 vs. 27.9±118.0, p=0.046) (Figure).

Figure 1

Conclusion

Compared with traditional statin therapy, PCSK9i treatment resulted in a greater decrease in lipid component in non-culprit coronary plaques. Therefore, PCSK9i may be useful option in preventing from adverse coronary events for the patients with CAD.

Identification of geosmin biosynthetic gene in geosmin-producing colonial cyanobacteria Coelosphaerium sp. and isolation of geosmin non-producing Coelosphaerium sp. from brackish Lake Shinji in Japan

Geosmin is an earthy-muddy smelling compound produced in aquatic ecosystems by microorganisms including cyanobacteria. An increase in geosmin levels affecting the local fishery occurred in May 2007 in Lake Shinji, Japan, and geosmin-producing colonial cyanobacterium, Coelosphaerium sp. G2, was isolated from a water sample from the lake and identified. Cyanobacteria Coelosphaerium sp. is commonly found in Lake Shinji; however, prior to 2007, earthy-muddy odors were not a frequent issue. Further, there was no information regarding the geosmin biosynthetic gene in colonial cyanobacteria. Here, the geosmin biosynthetic gene (geoA) in strain G2 was identified and its nucleotide sequence was determined. It was found that geoA had 79% and 78% identity with geoA from filamentous geosmin-producing cyanobacteria Fischerella sp. PCC 9431 and geoA2 from Phormidium sp. P2r, respectively. The deduced amino acid sequence of GeoA consisted of two domains that were annotated as terpene cyclase. In 2015, geosmin non-producing Coelosphaerium sp. S3C5 was isolated from Lake Shinji and identified by morphological and genetic analyses. There was no difference in morphology or nucleotide sequences of 16S rRNA and 16S-23S internal transcribed spacer (ITS) between geosmin-producing and non-producing strains, which are therefore closely related and can exist in Lake Shinji. Distinguishing the two strains by observation under a microscope and sequencing of 16S rRNA and 16S-23S ITS have proven difficult. Inconsistency between the appearance of Coelosphaerium cells and the detection of the odor in water samples could therefore be attributed to dominance by the geosmin-producing strain or the non-producing strain. The increase in earthy smell is assumed to be caused by an increase in the geosmin-producing strain in Lake Shinji. Genetic analysis of geoA in Coelosphaerium sp. and the relative abundances of geosmin-producing and non-producing Coelosphaerium strains in Lake Shinji can be used to mitigate the economic damages caused by geosmin. Development of a molecular method to monitor the geosmin-producing strain in water ecosystems is equally important to alleviate the earthy smell caused by this particular strain.

Post-occlusional hyperemia for fractional flow reserve assessment and pull-back curve analysis

Balloon occlusion is a potential method for inducing hyperemia to measure post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR). The objective of this study was to determine the clinical usefulness of post-occlusional hyperemia. FFRs measured using post-occlusional hyperemia caused by 30 (FFR_occl30) and 60 s (FFR_occl60) of balloon occlusion after PCI were compared in 60 lesions from 60 patients. The duration of hyperemia was also measured. There was a strong correlation between FFR_occl30 and FFR_occl60 (r = 0.969, p < 0.01). The duration of hyperemia was significantly longer with FFR_occl60 than with FFR_occl30 (68 ± 23 vs. 37 ± 15 s, p < 0.01). The time required for pullback curve analysis was around 45 s. However, in 7 (12%) cases, the duration of hyperemia with FFR_occl60 was < 45 s, which was not enough for pull-back curve analysis. To predict the duration of hyperemia with FFR_occl60 ≥ 45 s, the receiver operating characteristic curve analysis revealed a cut-off value of 25 s of hyperemia with FFR_occl30. FFR_occl30 is sufficient for diagnostic purposes. FFR_occl60 is suitable for pull-back curve analysis in select cases based on predictions made using the duration of hyperemia with FFR_occl30.

Angiogram based fractional flow reserve in patients with dual/triple vessel coronary artery disease

OBJECTIVE

To assess the performance of angiography derived Fractional Flow Reserve (FFRangio) in multivessel disease (MVD) patients undergoing angiography.

BACKGROUND

FFR is the reference standard for physiologic assessment of coronary stenosis and guidance of revascularization, especially in patients with MVD, yet it remains grossly underutilized. The non-wire based FFRangio performs well in non-MVD patients, but its accuracy in MVD is unknown.

METHODS

A prospective clinical study was conducted at Gifu Heart Centre, Japan. Patients underwent physiologic assessment of all relevant coronary lesions using wire-based FFR (wbFFR) and FFRangio. Primary outcome was diagnostic performance (sensitivity, specificity, accuracy) for FFRangio with wbFFR as reference. Other outcomes were the correlation between wbFFR/FFRangio, time required for wbFFR/FFRangio measurements, and the effect of wbFFR/FFRangio on the reclassification of coronary disease severity.

RESULTS

Fifty patients (118 lesions in total) were included. Mean age was 72 ± 9 years, 72% were male, 36% had triple vessel disease and the average SYNTAX score was 13. The mean measurement of wbFFR and FFRangio were 0.83 ± 0.12 and 0.81 ± 0.11, respectively. Accuracy, sensitivity and specificity for FFRangio were 92.3% (95% CI 79.1-98.4%), 92.4% (95% CI 84.3-97.2%) and 92.4% (95% CI 87.4-97.3%), respectively. Pearson's r between wbFFR and FFRangio was 0.83. FFRangio measurement was faster than wbFFR (9.6 ± 3.4 vs. 15.0 ± 8.9 min, p < 0.001).

CONCLUSIONS

In patients with MVD, FFRangio shows good correlation and excellent diagnostic performance compared to wbFFR, and measuring FFRangio is faster than wbFFR. These results highlight the potential clinical benefits of utilizing FFRangio among patients with MVD.

A Precise Sampling Strip with Microstructures

This paper presents a precise sampling microstructure formed as a paper strip. We have been developing dialysis system that can be implanted into a human body as an artificial kidney. For the safe use of our artificial kidney, the patients' urine needs to be constantly monitored to detect the abnormal value of ion concentration essential for human life. We are conceiving the monitoring system based on sampling by a paper strip. In this study, we fabricated the strip consisting of slanted and interlocked micropillars for the sampling, known as synthetic microfluidic paper. The paper-like substrate can be fabricated with a well-controlled geometry and subsequently enables precise sampling. Through the conducted experiments, it was shown that synthetic microfluidic paper had better mechanical properties, showed more precision in sampling than paper filter as well as corresponding liquid holding capability to the paper filter. Our proposed paper-based sampling system is expected to lead to the development of minimally invasive ion monitoring system with quantitative sampling strip.

Determination of Trace Hydrazine in Environmental Water Samples by in situ Solid Phase Extraction

A simple and rapid in situ method for the determination of hydrazine based on the concentration of aldazine compound formed by the reaction of hydrazine with p-dimethylaminobenzaldehyde was developed. This method was based on solid-phase extraction using a Sep-Pak C18 cartridge, followed by the quantification of hydrazine using a spectrophotometric method. To a sample solution of environmental water, p-dimethylaminobenzaldehyde solution was added to form aldazine by the reaction with hydrazine. The solution was passed through a Sep-Pak C18 cartridge for the adsorption of aldazine. In the laboratory, the aldazine adsorbed on the Sep-Pak C18 cartridge was eluted by passing a hydrochloric acid-ethanol (1:10) solution through the cartridge, and the color intensity of the solution was measured at 457 nm. The limit of detection for the new method was 0.2 mgN L^-1 of hydrazine. The determination of hydrazine in solution was not influenced even by hydrogen sulfide and organic matter. This method was then applied to the brackish water of Lake Nakaumi in the eastern area of Shimane Prefecture, Japan. This method was used to determine hydrazine in freshwater, seawater and wastwater.

Effects of water turbulence on plant, sediment and water quality in reed (Phragmites australis) community

Even though the interaction between water movements and aquatic plant is crucial for the aquatic ecosystem management, the importance of water turbulence in this regard is not well documented. To add to our knowledge on the interaction between aquatic plant communities and water turbulence, this study examined turbulence, plant, sediment and water quality at the reed community (Phragmites australis) in the Lake Shinji, Japan. Observations were conducted along transects perpendicular to the shoreline. For each transect, reed communities were observed at land ward side, centre, water ward and the outside of the reed community. An elevated level of turbulence was observed outside compared to inside reed community, where the magnitude of turbulence decreased with distance into the community interior. A significant positive correlation was observed for turbulence and surface-dissolved oxygen where the latter was negatively correlated to reed density. Sediment composition was affected by water turbulence where the content of coarse particles positively correlated to turbulence. Accumulation of organic matter in anoxic sediments together with fine particles was observed under low turbulence. Our findings can offer insight into understanding the interactions between turbulence and aquatic plant communities.

Geosmin-producing Species of Coelosphaerium (Synechococcales, Cyanobacteria) in Lake Shinji, Japan

In Lake Shinji, Japan, periodic outbreaks of musty odour have occurred since mid-May 2007. Although the substance responsible for the odour was identified as geosmin, the odour-producing organism was unknown. We cultivated an axenic unialgal strain and determined that a species of Coelosphaerium (Synechococcales) was responsible for the production of geosmin in Lake Shinji. Our analysis was conducted using gas chromatography/mass spectrometry to determine the odorous compound. To determine the algae species, it was observed by optical microscopy to describe its morphological characteristics and the polymerase chain reaction was used to characterise the nucleotide sequence of the 16S rRNA gene and the 16S-23S rRNA internal transcribed spacer region. In addition, we explored the relationship between the number of cells of the Coelosphaerium sp. and the concentration of geosmin. In conclusion, geosmin, the cause of the musty odour in Lake Shinji in autumn 2009, was produced by Coelosphaerium sp., and to our knowledge, this is the first report of a geosmin-producing species in the family Coelosphaeriaceae.

Formation kinetics of particulate films in directional drying of a colloidal suspension

We observed the kinetics of formation of colloidal films through directional drying with a pinned drying interface. The volume fraction of particles accumulated at the pinned drying interface increased in two stages: it rapidly increased in the initial stage of drying and then slowly increased. The final filling factor of the dried films decreased with increasing drying flux. We found a threshold drying flux for the formation of colloidal films below which uneven films are formed at the drying interface. This threshold flux is well explained by the competition between transport of particles by flow and transport by diffusion. We also found a minimum thickness for the formation of a packed layer of particles. The formation kinetics of a packed layer of particles due to drying was discussed.

Hitless wavelength-selective switch with quadruple series-coupled microring resonators using multiple-quantum-well waveguides

We demonstrate a hitless wavelength-selective switch (WSS) based on InGaAs/InAlAs five-layer asymmetric coupled quantum well (FACQW) quadruple series-coupled microring resonators. The WSS is driven by the electric-field-induced change in refractive index in the FACQW core layer caused by the quantum-confined Stark effect (QCSE) for high-speed operation. The WSS with high-mesa waveguides is fabricated on a molecular beam epitaxy-grown wafer by dry etching. The fabricated WSS consists of four microrings, each with a round-trip length of 350 μm and five directional couplers with shallow grooves. A boxlike spectral response and hitless switching with higher extinction ratios than a double series-coupled microring resonator are successfully demonstrated. In addition, we propose the improvement of switching characteristics by controlling the coupling efficiencies at the directional couplers.

Hitless wavelength-selective switch based on quantum well second-order series-coupled microring resonators

A hitless wavelength-selective switch (WSS) based on InGaAs/InAlAs multiple quantum well (MQW) second-order series-coupled microring resonators is proposed and fabricated. In the core layer, a five-layer asymmetric coupled quantum well (FACQW) structure is employed. The WSS is driven by the electrorefractive index change in the FACQW core layer caused by the quantum-confined Stark effect (QCSE). The wafer for the WSS is grown by molecular beam epitaxy and waveguide structures are formed by dry etching. Boxlike spectrum responses and hitless switching characteristics of the WSS are successfully demonstrated for the first time. The change in coupling efficiency at a coupler between a ring and a busline and between rings and its effect on the switching characteristics are also discussed.

[Mitral regurgitation in heart failure. Surgical therapy]

The optimal treatment of mitral regurgitation concomitant to heart failure remains controversial. A lack of consensus between cardiologists and cardiac surgeons, because of limited studies and heterogeneous data, has led to vaguely defined guidelines and different handling in the clinical routine in the past. However, progress in the operative management with excellent results of individual experienced centers suggests that a variety of patients might benefit from surgical therapy. Each patient should be evaluated individually regarding the benefits of surgical therapy which requires an interdisciplinary approach ("heart team") due to the complex pathophysiology and demanding diagnostics.