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Abstract Background Growing evidence demonstrates that maternal nutrition is crucial for the health of the mother-to-be, and early life course of the offspring. However, for most micronutrients, guidelines are inconsistent. This Delphi study aimed to investigate the level of expert consensus on maternal nutrition and micronutrient needs during preconception, pregnancy and lactation. Methods We conducted a two-round web-based Delphi survey on various topics including general approaches to diet and supplement use, and existing guidelines. For the periods of preconception, pregnancy and lactation, questions focused on the importance and strength of evidence for supplement use with the following micronutrients for low- and high-risk populations: folic acid, choline, iodine, magnesium, calcium, iron, selenium, docosahexaenoic acid (DHA), and vitamins B1, B2, B6, B12, D and K. Results Thirty-five experts participated in the panel, who were healthcare professionals (HCPs), researchers and joint HCP-researchers with expertise in nutrition, gynaecology and/or obstetrics. Panellists reached consensus on the importance of diet and dietary supplement use during pregnancy and agreed on the lack of clarity and consistency in current guidelines, and the need for education in these areas for HCPs, pregnant people and the general population. For general low-risk populations, there was consensus on the importance of supplement use with iron and vitamin D from preconception through lactation, with folic acid and iodine from preconception through the second and third trimesters, respectively, with DHA from the first trimester through lactation and with calcium during lactation. Panellists agreed that the evidence for supplement use with each of these micronutrients during these phases to improve outcomes and/or foetal development is strong, except for vitamin D (preconception), DHA (first trimester), and iron (both periods). There was also consensus that supplement use advice should be tailored for people following vegan/vegetarian diets, restricted diets due to food intolerances, obesity, polycystic ovary syndrome, diabetes mellitus, and previous nutrition-related pregnancy complications. Conclusion The findings revealed robust consensus on various aspects of maternal nutrition, including the need for education, the lack of consistency in current guidelines on supplement use, the importance of supplement use across specific phases of pregnancy and the at-risk groups requiring tailored approaches.

The objective of this research is to evaluate four distinct models for multi-population mortality projection in order to ascertain the most effective approach for forecasting the impact of the COVID-19 pandemic on mortality. Utilizing data from the Human Mortality Database for five countries—Finland, Germany, Italy, the Netherlands, and the United States—the study identifies the generalized additive model (GAM) within the age–period–cohort (APC) analytical framework as the most promising for precise mortality forecasts. Consequently, this model serves as the basis for projecting the impact of the COVID-19 pandemic on future mortality rates. By examining various pandemic scenarios, ranging from mild to severe, the study concludes that projections assuming a diminishing impact of the pandemic over time are most consistent, especially for middle-aged and elderly populations. Projections derived from the superior GAM-APC model offer guidance for strategic planning and decision-making within sectors facing the challenges posed by extreme historical mortality events and uncertain future mortality trajectories.

β-type Ti–Nb alloys are promising materials for load-bearing implant applications with improved mechanical biofunctionality and biocompatibility. In this work, the electrochemical and tribo-electrochemical behaviour of laser powder bed fusion (LPBF) produced β-type Ti–42Nb alloy processed via Gaussian and top hat laser was investigated and compared with commercial grade β-type Ti–45Nb and α+β-type Ti–6Al–4V ELI. Electrochemical impedance spectroscopy (EIS) and potentiodynamic polarization experiments were performed in phosphate-buffered saline (PBS) for corrosion behaviour. Tribocorrosion behaviour was studied under open circuit potential (OCP) conditions in PBS by using a reciprocating pin-on-disk tribometer. The passivation nature of the LPBF alloys is more decisive than the microstructural particularities for electrochemical behaviour. The overall corrosion response is similar due to the protective nature of the passive films formed on Ti alloys. Ti–6Al–4V ELI exhibits the best corrosion performance among all tested alloys with lower corrosion and passivation current density values. However, LPBF-produced alloys exhibit less reactive surfaces with better passive film properties compared to Ti–45Nb. In addition, EIS results revealed that passive film resistance values are higher for LPBF-produced alloys than conventionally produced Ti–45Nb. LPBF-produced alloys exhibit better tribo-electrochemical behaviour compared to Ti–45Nb. The differences in volume loss are mainly attributed to the microhardness of the alloys and the volume loss is dominated by mechanical wear. The alloys produced with LPBF show promising corrosion and tribocorrosion performance to be a potential candidate for load-bearing implant applications.

SUMMARY Denosumab is a potent antiresorptive medication, commonly used in the treatment of osteoporosis, as well as in a variety of other diseases. Potential adverse rebound effects after its cessation include a loss in bone mineral density and an increased risk of osteoporotic fractures. Hypercalcemia is a less frequently reported rebound phenomenon after denosumab discontinuation, that may pose a diagnostic challenge to physicians as a rare non-parathyroid hormone (PTH) dependent cause of hypercalcemia. In our case, a 47-year-old male presented with rebound hypercalcemia after denosumab cessation during follow-up after surgical treatment for parathyroid carcinoma. This non-PTH-dependent hypercalcemia resolved after re-initiation of denosumab. We performed a systematic literature review on rebound hypercalcemia after denosumab cessation and identified 52 individual patient cases. Children appear to be more prone to developing rebound hypercalcemia, which could be attributed to their higher baseline bone turnover, underlying conditions, or denosumab dosage regimens. In most cases, patients initially presented with acute and often severe symptoms of hypercalcemia that occur from 1.75 to 9 months after denosumab cessation (4 to 9 months in adults). Most effective treatment approaches to sufficiently decrease serum calcium levels were bisphosphonates or re-administration of denosumab. A watch and wait strategy may be sufficient in asymptomatic cases, which are less common and probably underdiagnosed. Subsequent antiresorptive treatment after denosumab cessation, which is a common practice in osteoporosis treatment, may reduce the risk of rebound hypercalcemia. As denosumab is a frequently used drug in patients with advanced malignant diseases and rebound hypercalcemia with low PTH levels may raise the suspicion for skeletal metastases, awareness of this rebound effect may be for particular relevance in such settings.

Abstract Aims Chronic heart failure is associated with a bone‐catabolic state and increases the risk of osteoporosis and fractures. Prospective studies investigating the clinical relevance of bone disease in heart failure are lacking. We aimed to assess the prevalence and prognostic impact of osteoporosis and vertebral fractures (VFs) in chronic heart failure with reduced ejection fraction (HFrEF). Methods and results Symptomatic outpatients with chronic heart failure and a previous diagnosis of overtly reduced left ventricular ejection fraction

BackgroundApart from the well-established skeletal effects, vitamin D has been explored as a secretagogue influencing various adipokines, including adiponectin and irisin. Recent evidence suggests that specific forms of 25-Hydroxyvitamin D (25(OHD), such as free and bioavailable 25(OH)D, may provide more accurate measurements of vitamin D status. The relationship between vitamin D status and serum irisin and adiponectin concentrations remains largely unexplored, particularly during pregnancy.MethodsWe analyzed data from 67 healthy maternal-neonatal pairs from Northern Greece at birth. Biochemical and hormonal tests were conducted on each maternal-neonatal pair. The vitamin D forms were estimated using validated mathematical models. Subsequently, regression analyses were conducted to determine the association between the vitamin D forms and adipokine levels.ResultsBioavailable maternal 25(OH)D was inversely associated with neonatal irisin concentrations [β=-73.46 (-140.573 to -6.341), p=0.034]. No other associations were observed between maternal vitamin D status and neonatal adipokine concentrations.ConclusionIn conclusion, maternal bioavailable vitamin D concentrations are inversely associated with neonatal serum irisin concentrations, warranting further studies to evaluate the underlying mechanisms for this finding.

Lattices based on triply periodic minimal surfaces (TPMS) are attracting increasing interest in seminal industries such as bone tissue engineering due to their excellent structure-property relationships. However, the potential can only be exploited if their structural integrity is ensured. This requires a fundamental understanding of the impact of imperfections that arise during additive manufacturing. Therefore, in the present study, the structure-property relationships of eight TPMS lattices, including their imperfections, are investigated experimentally and numerically. In particular, the focus is on biomimetic network TPMS lattices of the type Schoen I-WP and Gyroid, which are fabricated by laser powder bed fusion from the biocompatible alloy Ti-42Nb. The experimental studies include computed tomography measurements and compression tests. The results highlight the importance of process-related imperfections on the mechanical performance of TPMS lattices. In the numerical work, firstly the as-built morphology is artificially reconstructed before finite element analyses are performed. Here, the reconstruction procedure previously developed by the same authors is used and validated on a larger experimental matrix before more advanced calculations are conducted. Specifically, the reconstruction reduces the numerical overestimation of stiffness from up to 341% to a maximum of 26% and that of yield strength from 66% to 12%. Given a high simulation accuracy and flexibility, the presented procedure can become a key factor in the future design process of TPMS lattices.

This study aims to develop novel low-modulus, corrosion-resistant Ti-based alloys with enhanced antimicrobial properties for bone-related implant applications. Novel β-type (Ti–45Nb)-based alloys with minor additions of the antibacterial elements Ga and/or Cu (up to 4 wt.%) were produced by a two-step casting process followed by homogenization treatment. Three nominal compositions (Ti–45Nb)96-4 Ga, (Ti–45Nb)96–4Cu and (Ti–45Nb)96-2 Ga–2Cu (wt.%) were prepared based on alloy design approach using [Mo]eq and electron per atom (e/a) ratio. The influence of Ga and/or Cu addition on the phase constitution, mechanical response and corrosion characteristics in simulated body fluids (PBS, 37.5 °C) has been investigated. X-ray diffraction studies displayed a single β phase structure for all alloys, with an observed lattice contraction evidenced by the reduction of lattice parameters during Rietveld analysis. Homogenous equiaxed microstructures with grain sizes ranging from 55 μm up to 323 μm were observed for (Ti–45Nb)96-4 Ga, (Ti–45Nb)96-2 Ga–2Cu and (Ti–45Nb)96–4Cu alloys. The alloys displayed excellent plasticity with no cracking, or fracturing during compression tests. Their tensile strength, Young's modulus, maximum tensile strain and elastic energy were measured in the ranges of 544–681 MPa, 73–78 GPa, 17–28% and 2.5–3.7 MJ/m3, in the order (Ti–45Nb)96-4 Ga > (Ti–45Nb)96-2 Ga–2Cu > (Ti–45Nb)96–4Cu. In addition, it has been observed that micro-alloying Ti–Nb alloy with Ga and/or Cu posed no deleterious effect on the corrosion resistance in simulated body fluid conditions. The improvement in strength of the developed alloys has been discussed based on grain boundary and solid-solution strengthening, whereas the improved plasticity is attributed to work hardening.

Summary: Branched-chain amino acids (BCAAs) are effectors of metabolic diseases, but their impact on mortality is largely unknown. We investigated the association of BCAA with risk factors and mortality in 2,236 participants of the Ludwigshafen Risk and Cardiovascular Health (LURIC) study using linear and Cox regression. Adiponectin, hemoglobin, C-peptide, hemoglobin A1c, and homoarginine showed the strongest association with BCAA concentration (all p

SUMMARY Acute suppurative thyroiditis (AST) is a rare but potentially life-threatening thyroid disease with a high mortality if left untreated. Thus, differentiation from other thyroid disorders is highly important in clinical practice. A 22-year-old male patient was admitted to a tertiary care hospital with cervical pain, palpitations, thyrotoxicosis, and an inhomogeneously enlarged right thyroid lobe. In view of the clinical findings, subacute thyroiditis (SAT) was suspected and treatment with glucocorticoids was started. After initial amelioration, the patient developed cervical erythema, fever, and recurrent pain. A CT scan showed extensive phlegmonous inflammation and abscess formation, suggestive of AST. We started immediate empiric antibiotic therapy and performed surgical drainage of the abscess formations. Subsequently, the patient developed hypoxic respiratory failure, leading to ICU admission and intermittent need for non-invasive ventilation. Blood and abscess cultures were positive for Streptococcus anginosus. If left untreated, AST represents a potentially life-threatening disease. Thus, in clinically doubtful cases, liberal further assessment by means of cervical CT scans or fine needle aspiration biopsy are strongly advised.

Lattices based on triply periodic minimal surfaces (TPMS) have recently attracted increasing interest, but their additive manufacturing (AM) is fraught with imperfections that compromise their structural integrity. Initial research has addressed the influence of process-induced imperfections in lattices, but so far numerical work for TPMS lattices is insufficient. Therefore, in the present study, the structure–property relationships of TPMS lattices, including their imperfections, are investigated experimentally and numerically. The main focus is on a biomimetic Schoen I-WP network lattice made of laser powder bed fusion (LPBF) processed Ti-42Nb designed for bone tissue engineering (BTE). The lattice is scanned by computed tomography (CT) and its as-built morphology is examined before a modeling procedure for artificial reconstruction is developed. The structure–property relationships are analyzed by experimental and numerical compression tests. An anisotropic elastoplastic material model is parameterized for finite element analyses (FEA). The numerical results indicates that the reconstruction of the as-built morphology decisively improves the prediction accuracy compared to the ideal design. This work highlights the central importance of process-related imperfections for the structure–property relationships of TPMS lattices and proposes a modeling procedure to capture their implications.

Abstract Background Coronavirus disease 19 (COVID-19)-associated pulmonary aspergillosis (CAPA) emerged as important fungal complications in patients with COVID-19-associated severe acute respiratory failure (ARF). Whether mould active antifungal prophylaxis (MAFP) can prevent CAPA remains elusive so far. Methods In this observational study, we included all consecutive patients admitted to intensive care units with COVID-19-associated ARF between September 1, 2020, and May 1, 2021. We compared patients with versus without antifungal prophylaxis with respect to CAPA incidence (primary outcome) and mortality (secondary outcome). Propensity score adjustment was performed to account for any imbalances in baseline characteristics. CAPA cases were classified according to European Confederation of Medical Mycology (ECMM)/International Society of Human and Animal Mycoses (ISHAM) consensus criteria. Results We included 132 patients, of whom 75 (57%) received antifungal prophylaxis (98% posaconazole). Ten CAPA cases were diagnosed, after a median of 6 days following ICU admission. Of those, 9 CAPA cases were recorded in the non-prophylaxis group and one in the prophylaxis group, respectively. However, no difference in 30-day ICU mortality could be observed. Thirty-day CAPA incidence estimates were 1.4% (95% CI 0.2–9.7) in the MAFP group and 17.5% (95% CI 9.6–31.4) in the group without MAFP (p = 0.002). The respective subdistributional hazard ratio (sHR) for CAPA incidence comparing the MAFP versus no MAFP group was of 0.08 (95% CI 0.01–0.63; p = 0.017). Conclusion In ICU patients with COVID-19 ARF, antifungal prophylaxis was associated with significantly reduced CAPA incidence, but this did not translate into improved survival. Randomized controlled trials are warranted to evaluate the efficacy and safety of MAFP with respect to CAPA incidence and clinical outcomes.

A constitutive model was developed to characterize the static recrystallization (SRX) and evolution of the grain size of the industrially relevant press-hardening steel, 22MnB5, subsequent to the hot forming of sheet metal. Isothermal stress relaxation tests were conducted using the BAEHR 805 A/D thermomechanical simulator, encompassing a temperature range of 950 to 1050 °C, prestrain levels ranging from 0.01 to 0.1, and strain rates spanning from 0.01 to 0.8 s−1. The results obtained from the isothermal stress relaxation tests facilitated the formulation of an Avrami equation-based model, which aptly describes the kinetics of SRX in relation to the temperature, prestrain, and strain rate. Notably, an increase in temperature led to accelerated recrystallization kinetics, signifying temperature-dependent behavior. When the temperature increased from 950 to 1050 °C, the recrystallization time was reduced to approximately one-third. Additionally, the prestrain exhibited a positive influence on the acceleration of SRX kinetics. A quintupling of the prestrain from 0.01 to 0.05 resulted in a reduction of the static recrystallization duration to approximately one-fifth. Among the parameters studied, the strain rate had the least impact on the SRX kinetics, as doubling the strain rate from 0.01 to 0.8 only resulted in a halving of the recrystallization duration. Moreover, an analysis of the microstructural evolution in response to the forming parameters was undertaken. While the grain-size investigation post-isothermal stress relaxation tests provided results in line with the SRX kinetics calculations, the observed effects were comparatively subdued. Furthermore, a comprehensive examination was conducted using electron backscatter diffraction (EBSD) analysis, aiming to explore the effects of specific stress relaxation states on the morphology of martensite. The findings reveal fully recrystallized globulitic microstructures, characterized by relatively minor differences among them.

Abstract Background This study aimed to quantify the potential survival benefit of convalescent plasma therapy (CVP) in critically ill patients with acute respiratory failure related to coronavirus disease-2019 (COVID-19). Methods This is a single-center prospective observational cohort study in COVID-19 patients with acute respiratory failure. Immediately after intensive care unit (ICU) admission patients were allocated to CVP treatment following pre-specified criteria to rapidly identify those patients potentially susceptible for this treatment. A propensity score adjustment [inverse probability of treatment weighted (IPTW) analysis] was implemented to account rigorously for imbalances in prognostic variables between the treatment groups. Results We included 120 patients of whom 48 received CVP. Thirty percent were female with a median age of 66 years [25th–75th percentile 54–75]. Eighty-eight percent of patients presented with severe acute respiratory failure as displayed by a median paO2/FiO2 ratio (Horowitz Index) of 92 [77–150]. All patients required any kind of ventilatory support with more than half of them (52%) receiving invasive ventilation. Thirty-day ICU overall survival (OS) was 69% in the CVP group and 54% in the non-CVP group (log-rank p = 0.049), respectively. After weighing the time-to-event data for the IPTW, the favorable association between CVP and OS became even stronger (log-rank p = 0.035). Moreover, an exploratory analysis showed an overall survival benefit of CVP therapy for patients with non-invasive ventilation (Hazard ratio 0.12 95% CI 0.03–0.57, p = 0.007) Conclusion Administration of CVP in patients with acute respiratory failure related to COVID-19 is associated with improved ICU survival rates.

Abstract Background Hyperprolactinaemia might cause adverse metabolic effects. The aim of our study was to compare parameters of body composition, glucose and lipid metabolism between untreated patients with prolactinoma and controls and to assess changes after initiation of cabergoline. Methods Case-control study with a retrospectively analyzed follow-up in patients with prolactinoma after initiation of cabergoline therapy. Results 21 patients with prolactinoma (9 micro- and 12 macroprolactinomas; 7 females) and 30 controls were analyzed. Patients with prolactinoma had significantly higher BMI than controls; fat mass did not differ between groups. Only men - but not women - with prolactinoma had significantly higher fat mass at all six sites measured compared to controls. Levels of LDL (130 (107–147.5) vs. 94.5 (80–127.5) mg/dl, p

Abstract Aims Vitamin D supplementation is widely used in the clinical setting, but its effects on mortality and cardiovascular outcomes in patients with heart failure are unclear. This paper reports outcome data that were collected during follow‐up of 3 years after closure of the EVITA trial (a 3 year randomized, placebo‐controlled, intervention study with 4000 IU vitamin D daily in patients with advanced heart failure), to capture potential latency effects of vitamin D supplementation on clinical outcomes. Methods and results The prespecified primary endpoint was overall mortality. Secondary endpoints included hospitalization, mechanical circulatory support implantation, high urgent listing for heart transplantation, and heart transplantation. For group comparisons, we used Cox regression models with a time‐dependent categorical covariate. The calculated net difference in circulating 25‐hydroxyvitamin D between the vitamin D and placebo groups dropped from 60.9 nmol/L at the end of the active study period to 3.2 nmol/L at the end of the post‐intervention period. During the entire 6 year period, 73 patients (36.5%) died in the placebo group and 76 (38.8%) in the vitamin D group. Out of these 149 patients, 36 and 39 died during the first 3 years, and 37 and 37 during the second 3 years, respectively. The hazard ratio (HR) for mortality in the vitamin D versus the placebo group was 1.06 [95% confidence interval (CI): 0.68–1.66] for the first 3 years and 1.07 (95% CI: 0.68–1.70) for the 3 year post‐intervention follow‐up. Compared with the placebo group, the HRs for hospitalization and for mechanical circulatory support implant were significantly higher in the vitamin D group during vitamin D supplementation (HR = 1.31, 95% CI: 1.01–1.68 and HR = 2.01, 95% CI: 1.08–3.76, respectively) but not after vitamin D discontinuation (HR = 1.10, 95% CI: 0.62–1.94 and HR = 0.99, 95% CI: 0.38–2.56, respectively). There was no significant time‐dependent effect on the risk of high urgent listing for heart transplantation and heart transplantation. Conclusions No beneficial latency effects of vitamin D supplementation on overall mortality could be demonstrated. Instead, the disappearance of unfavourable findings in the vitamin D group (higher HRs for hospitalization and for mechanical circulatory support implant) after vitamin D discontinuation supports the assumption of adverse vitamin D effects on the cardiovascular system at doses of 4000 IU daily.

BackgroundMethimazole (MMI) is the first-line treatment for patients with Graves’ disease (GD). While there are empirical recommendations for initial MMI doses, there is no clear guidance for subsequent MMI dose titrations. We aimed to (a) develop a mathematical model capturing the dynamics of free thyroxine (FT4) during MMI treatment (b), validate this model by use of numerical simulation in comparison with real-life patient data (c), develop the software application Digital Thyroid (DigiThy) serving either as a practice tool for treating virtual patients or as a decision support system with dosing recommendations for MMI, and (d) validate this software framework by comparing the efficacy of its MMI dosing recommendations with that from clinical endocrinologists.MethodsBased on concepts of automatic control and by use of optimization techniques, we developed two first order ordinary differential equations for modeling FT4 dynamics during MMI treatment. Clinical data from patients with GD derived from the outpatient clinic of Endocrinology at the Medical University of Graz, Austria, were used to develop and validate this model. It was subsequently used to create the web-based software application DigiThy as a simulation environment for treating virtual patients and an autonomous computer-aided thyroid treatment (CATT) method providing MMI dosing recommendations.ResultsBased on MMI doses, concentrations of FT4, thyroid-stimulating hormone (TSH), and TSH-receptor antibodies (TRAb), a mathematical model with 8 patient-specific constants was developed. Predicted FT4 concentrations were not significantly different compared to the available consecutively measured FT4 concentrations in 9 patients with GD (52 data pairs, p=0.607). Treatment success of MMI dosing recommendations in 41 virtually generated patients defined by achieved target FT4 concentrations preferably with low required MMI doses was similar between CATT and usual care. Statistically, CATT was significantly superior (p

Additive manufacturing of near β-type Ti-13Nb-13Zr alloys using the laser powder bed fusion process (LPBF) opens up new avenues to tailor the microstructure and subsequent macro-scale properties that aids in developing new generation patient-specific, load-bearing orthopedic implants. In this work, we investigate a wide range of LPBF parameter space to optimize the volumetric energy density, surface characteristics and melt track widths to achieve a stable process and part density of greater than 99 %. Further, optimized sample states were achieved via thermal post-processing using standard capability aging, super-transus (900 °C) and sub-transus (660 °C) heat treatment strategies with varying quenching mediums (air, water and ice). The applied heat treatment strategies induce various fractions of α, martensite (α', α'') in combination with the β phase and strongly correlated with the observed enhanced mechanical properties and a relatively low elastic modulus. In summary, our work highlights a practical strategy for optimizing the mechanical and corrosion properties of a LPBF produced near β-type Ti-13Nb-13Zr alloy via careful evaluation of processing and post-processing steps and the interrelation to the corresponding microstructures. Corrosion studies revealed excellent corrosion resistances of the heat-treated LPBF samples comparable to wrought Ti-13Nb-13Zr alloys.

The ß-type Ti-42Nb alloy was processed by laser powder bed fusion (LPBF) with an infrared top hat laser configuration aiming to control the Young’s modulus by creating an adapted crystallographic texture. Utilizing a top hat laser, a microstructure with a strong 〈0 0 1〉 texture parallel to the building direction and highly elongated grains was generated. This microstructure results in a strong anisotropy of the Young’s modulus that was modeled based on the single crystal elastic tensor and the experimental texture data. Tensile tests along selected loading directions were conducted to study the mechanical anisotropy and showed a good correlation with the modeled data. A Young’s modulus as low as 44 GPa was measured parallel to the building direction, which corresponds to a significant reduction of over 30% compared to the Young’s modulus of the Gaussian reference samples (67–69 GPa). At the same time a high 0.2% yield strength of 674 MPa was retained. The results reveal the high potential of LPBF processing utilizing a top hat laser configuration to fabricate patient-specific implants with an adapted low Young’s modulus along the main loading direction and a tailored mechanical biofunctionality.

Hypothyroidism is a condition where the patient’s thyroid gland cannot produce sufficient thyroid hormones (mainly triiodothyronine and thyroxine). The primary cause of hypothyroidism is autoimmune-mediated destruction of the thyroid gland, referred to as Hashimoto’s thyroiditis. A patient’s desired thyroid hormone concentration is achieved by oral administration of thyroid hormone, usually levothyroxine. Establishing individual levothyroxine doses to achieve desired thyroid hormone concentrations requires several patient visits. Additionally, clear guidance for the dosing regimen is lacking, and significant inter-individual differences exist. This study aims to design a digital automatic dosing algorithm for patients suffering from Hashimoto’s thyroiditis. The dynamic behaviour of the relevant thyroid function is mathematically modelled. Methods of automatic control are exploited for the design of the proposed robust model-based levothyroxine dosing algorithm. Numerical simulations are performed to evaluate the mathematical model and the dosing algorithm. With the help of the developed controller thyroid hormone concentrations of patients, emulated using Thyrosim, have been regulated under the euthyroid state. The proposed concept demonstrates reliable responses amidst varying patient parameters. Our developed model provides a useful basis for the design of automatic levothyroxine dosing algorithms. The proposed robust feedback loop contributes to the first results for computer-assisted thyroid dosing algorithms.

Accumulating evidence supports the potential protective effects of vitamin D against chronic diseases such as Alzheimer’s disease, autoimmune diseases, cancers, cardiovascular disease (ischaemic heart disease and stroke), type 2 diabetes, hypertension, chronic kidney disease, stroke, and infectious diseases such as acute respiratory tract diseases, COVID-19, influenza, and pneumonia, as well as adverse pregnancy outcomes. The respective evidence is based on ecological and observational studies, randomized controlled trials, mechanistic studies, and Mendelian randomization studies. However, randomized controlled trials on vitamin D supplementation have largely failed to show benefits, probably due to poor design and analysis. In this work, we aim to use the best available evidence on the potential beneficial effects of vitamin D to estimate the expected reduction in incidence and mortality rates of vitamin D-related diseases in the Kingdom of Saudi Arabia and the United Arab Emirates if minimum serum 25(OH)D concentrations were to be raised to 30 ng/mL. Estimated reductions by 25% for myocardial infarction incidence, 35% for stroke incidence, 20 to 35% for cardiovascular disease mortality, and 35% for cancer mortality rates depicted a promising potential for raising serum 25(OH)D. Methods to increase serum 25(OH)D concentrations at the population level could include food fortification with vitamin D3, vitamin D supplementation, improved dietary vitamin D intake, and sensible sun exposure.

Objective: Cardiovascular disease manifestation and several associated surrogate markers, such as vitamin D, have shown substantial seasonal variation. A promising cardiovascular biomarker, soluble ST2 (sST2), has not been investigated in this regard – we therefore determined if systemic levels of sST2 are affected by seasonality and/or vitamin D in order to investigate their clinical interrelation and usability. Design: sST2 levels were measured in two cohorts involving hypertensive patients at cardiovascular risk, the Styrian Vitamin D Hypertension Trial (study A; RCT design, 8 weeks 2800 IU cholecalciferol daily) and the Ludwigshafen Risk and Cardiovascular Health Study (LURIC; study B; cross-sectional design). Methods: The effects of a vitamin D intervention on sST2 levels were determined in study A using ANCOVA, while seasonality of sST2 levels was determined in study B using ANOVA. Results: The concentrations of sST2 remained unchanged by a vitamin D intervention in study A, with a mean treatment effect (95% confidence interval) of 0.1 (−0.6 to 0.8) ng/mL; P = 0.761), despite a rise in 25(OH)D (11.3 (9.2–13.5) ng/mL; P < 0.001) compared to placebo. In study B, seasonal variations were present in 25(OH)D levels in men and women with or without heart failure (P < 0.001 for all subgroups), while sST2 levels remained unaffected by the seasons in all subgroups. Conclusions: Our study provides the first evidence that systemic sST2 levels are not interrelated with vitamin D levels or influenced by the seasons in subjects at cardiovascular risk.

Objective: PTH can be oxidised in vivo, rendering it biologically inactive. Non-oxidised PTH (n-oxPTH) may therefore give a better image of the hormonal status of the patient. While vitamin D supplementation decreases total PTH (tPTH) concentration, the effect on n-oxPTH concentration is unexplored. We investigated the effect of vitamin D on n-oxPTH concentration in comparison to tPTH and compared the correlations between parameters of calcium, bone and lipid metabolism with n-oxPTH and tPTH. Methods: N-oxPTH was measured in 108 vitamin D-insufficient (25(O H)D

The project “Stress Corrosion Cracking of Zr-based Bulk Metallic Glasses” (SCC of Zr-BMGs) within PP1594 mainly dealt with mechanical–corrosive interactions and failure of this class of metastable materials. It focused on one of the most application-relevant zirconium (Zr)-BMG, Vit(reloy) 105, with composition Zr52.5Cu17.9Ni14.6Al10Ti5 (at.%). Even though this BMG is known as an extraordinary glass former, the metallurgical processing is still a critical issue. In contrast to conventional processing, i.e., arc melting of master alloy ingots from single constituents, a different route using binary pre-alloys for the master alloys production was applied and led to superior mechanical properties upon mechanical testing under tensile and three-point-bending (3PB) conditions in air. As a reference and for a detailed understanding of failure, fracture, and cracking of Zr-based BMG in air, notched specimen 3PB experiments with in situ microscopic observation were done and the still controversial interpretation of the mechanical behavior of BMG in the framework of fracture mechanics was addressed. The specimen from the in situ 3PB tests served for transmission electron microscopy (TEM) investigations on the structural nature of shear bands in BMG on the atomistic scale. Altogether, complete crack paths could be observed and analyzed, and based on this, details of the shear band-driven crack growth are described. While in first SCC studies using a newly developed setup full cross section (3PB) bars were investigated, in recent in situ experiments, notched specimens were tested in 0.01 M NaCl, yielding strong evidence for a catastrophic failure due to hydrogen embrittlement (HE). The known susceptibility to pitting corrosion in halide-containing environments is only the initial stage for failure under SCC conditions. Once pitting is initiated, the local electrode potential is severely reduced. Further, the hydrolysis reaction of oxidized Zr4+ to zirconyl ions ZrO2+ during local BMG dissolution produces H+ and, thus, a local acidic environment that enables proton reduction and hydrogen absorption in the stressed BMG region. The peculiar failure and fracture surface characteristics as well as the proven local reduction of the pH value in the vicinity of the notch during in situ experiments clearly account for the proposed HE-SCC failure mechanism.

The purpose of this review was to assess recent evidence regarding the effects of low vitamin D levels on some highly prevalent clinical conditions of postmenopausal women. We reviewed and selected recent literature regarding menopause-related conditions associated with vitamin D deficiency and interventions to manage them. Low circulating 25-hydroxyvitamin D (25(OH)D) levels related to menopause are linked to diet, lifestyle, changes in body composition, insulin sensitivity, and reduced physical activity. Vitamin D supplementation increases serum 25(OH)D levels while normalizing parathyroid hormone and bone markers, and in women with serum 25(OH)D levels below 10 ng/ml supplementation may improve bone mineral density. Low vitamin D status has been associated with the metabolic syndrome, high triglyceride levels, and low high-density lipoprotein cholesterol levels. When compared with placebo, vitamin D supplementation may lower the risk of the metabolic syndrome, hypertriglyceridemia, and hyperglycemia. There is an inverse relationship between fat mass and serum 25(OH)D levels and, therefore, the dosage of supplementation should be adjusted according to the body mass index. Although vitamin D supplementation may improve glucose metabolism in prediabetic subjects, data regarding muscle strength are conflictive. There is evidence that vitamin D over-treatment, to reach extremely high circulating 25(OH)D levels, does not result in better clinical outcomes. The identification and treatment of vitamin D deficiency in postmenopausal women may improve their general health and health outcomes. Vitamin D supplementation should preferably be based on the use of either cholecalciferol or calcifediol.

Background: Women with polycystic ovary syndrome (PCOS) are more prone to autoimmune thyroiditis, and both disorders lead to subfertility and pregnancy-related complications. The aim of this study was to investigate whether mothers with and without PCOS and their offspring have comparable thyroid parameters at term and how thyroid parameters are associated with perinatal outcome in this population. Methods: This cross-sectional observational study was performed in a single academic tertiary hospital in Austria. Seventy-nine pregnant women with PCOS and 354 pregnant women without PCOS were included. Blood samples were taken from the mother and cord blood at birth. Primary outcome parameters were maternal and neonatal thyroid parameters at delivery. Secondary outcome parameters were the composite complication rate per woman and per neonate. Results: Thyroid dysfunction was more prevalent among PCOS women (p < 0.001). At time of birth, free triiodothyronine (fT3) levels were significantly lower in PCOS than in non-PCOS women (p = 0.005). PCOS women and their neonates had significantly higher thyreoperoxidase antibody (TPO-AB) levels (p = 0.001). Women with elevated TPO-AB had a significantly higher prevalence of hypothyroidism (p < 0.001). There was a significant positive correlation between maternal and neonatal free thyroxine, fT3 and TPO-AB levels. There were no significant differences in thyroid parameters between women or neonates with or without complications. Conclusions: Our results demonstrate a higher prevalence of thyroid dysfunction and autoimmunity in PCOS women, supporting a common etiology of both disorders. We were not able to show an association between complication rate and thyroid parameters.

Background: Accumulating evidence from animal and human studies suggests that vitamin D is involved in many functions of the reproductive system in both genders. Aim: The aim of this review was to provide an overview on the effects of vitamin D on polycystic ovary syndrome (PCOS) in women and androgen metabolism in men. Methods: We performed a systematic literature search in PubMed for relevant English language publications published from January 2012 until September 2017. Results and discussion: The vitamin D receptor and vitamin D-metabolizing enzymes are found in reproductive tissues of women and men. In women, vitamin D status has been associated with several features of PCOS. In detail, cross-sectional data suggest a regulatory role of vitamin D in PCOS-related aspects such as ovulatory dysfunction, insulin resistance as well as hyperandrogenism. Moreover, results from randomized controlled trials (RCTs) suggest that vitamin D supplementation may be beneficial for metabolic, endocrine and fertility aspects in PCOS. In men, vitamin D status has been associated with androgen levels and hypogonadism. Further, there is some evidence for a favorable effect of vitamin D supplementation on testosterone concentrations, although others failed to show a significant effect on testosterone levels. Conclusion: In summary, vitamin D deficiency is associated with adverse fertility outcomes including PCOS and hypogonadism, but the evidence is insufficient to establish causality. High-quality RCTs are needed to further evaluate the effects of vitamin D supplementation in PCOS women as well as on androgen levels in men.

Vitamin D deficiency is associated with multiple human pathologic conditions. In a genome-wide association study of 79,366 individuals, Jiang et al. replicate four and identify two new genetic loci for serum levels of 25-hydroxyvitamin D and find evidence for a shared genetic basis with autoimmune diseases.

Abstract Background Surface functionalization of orthopedic implants with pharmaceutically active agents is a modern approach to enhance osseointegration in systemically altered bone. A local release of strontium, a verified bone building therapeutic agent, at the fracture site would diminish side effects, which could occur otherwise by oral administration. Strontium surface functionalization of specially designed titanium-niobium (Ti-40Nb) implant alloy would provide an advanced implant system that is mechanically adapted to altered bone with the ability to stimulate bone formation. Methods Strontium-containing coatings were prepared by reactive sputtering of strontium chloride (SrCl2) in a self-constructed capacitively coupled radio frequency (RF) plasma reactor. Film morphology, structure and composition were investigated by scanning electron microscopy (SEM), time of flight secondary ion mass spectrometry (ToF-SIMS) and X-ray photoelectron spectroscopy (XPS). High-resolution transmission electron microscopy (HR-TEM) was used for the investigation of thickness and growth direction of the product layer. TEM lamellae were prepared using the focused ion beam (FIB) technique. Bioactivity of the surface coatings was tested by cultivation of primary human osteoblasts and subsequent analysis of cell morphology, viability, proliferation and differentiation. The results are correlated with the amount of strontium that is released from the coating in biomedical buffer solution, quantified by inductively coupled plasma mass spectrometry (ICP-MS). Results Dense coatings, consisting of SrOxCly, of more than 100 nm thickness and columnar structure, were prepared. TEM images of cross sections clearly show an incoherent but well-structured interface between coating and substrate without any cracks. Sr2+ is released from the SrOxCly coating into physiological solution as proven by ICP-MS analysis. Cell culture studies showed excellent biocompatibility of the functionalized alloy. Conclusions Ti-40Nb alloy, a potential orthopedic implant material for osteoporosis patients, could be successfully plasma coated with a dense SrOxCly film. The material performed well in in vitro tests. Nevertheless, the Sr2+ release must be optimized in future work to meet the requirements of an effective drug delivery system.

Abstract Cardiovascular risk assessment in patients with diabetes relies on traditional risk factors. However, numerous novel biomarkers have been found to be independent predictors of cardiovascular disease, which might significantly improve risk prediction in diabetic patients. We aimed to improve prediction of cardiovascular risk in diabetic patients by investigating 135 evolving biomarkers. Based on selected biomarkers a clinically applicable prediction algorithm for long-term cardiovascular mortality was designed. We prospectively enrolled 864 diabetic patients of the LUdwigshafen RIsk and Cardiovascular health (LURIC) study with a median follow-up of 9.6 years. Independent risk factors were selected using bootstrapping based on a Cox regression analysis. The following seven variables were selected for the final multivariate model: NT-proBNP, age, male sex, renin, diabetes duration, Lp-PLA2 and 25-OH vitamin D3. The risk score based on the aforementioned variables demonstrated an excellent discriminatory power for 10-year cardiovascular survival with a C-statistic of 0.76 (P

Abstract Vascular calcification resulting from hyperphosphatemia is a major determinant of mortality in chronic kidney disease (CKD). Vascular calcification is driven by aldosterone-sensitive osteogenic transformation of vascular smooth muscle cells (VSMCs). We show that even in absence of exogenous aldosterone, silencing and pharmacological inhibition (spironolactone, eplerenone) of the mineralocorticoid receptor (MR) ameliorated phosphate-induced osteo-/chondrogenic transformation of primary human aortic smooth muscle cells (HAoSMCs). High phosphate concentrations up-regulated aldosterone synthase (CYP11B2) expression in HAoSMCs. Silencing and deficiency of CYP11B2 in VSMCs ameliorated phosphate-induced osteogenic reprogramming and calcification. Phosphate treatment was followed by nuclear export of APEX1, a CYP11B2 transcriptional repressor. APEX1 silencing up-regulated CYP11B2 expression and stimulated osteo-/chondrogenic transformation. APEX1 overexpression blunted the phosphate-induced osteo-/chondrogenic transformation and calcification of HAoSMCs. Cyp11b2 expression was higher in aortic tissue of hyperphosphatemic klotho-hypomorphic (kl/kl) mice than in wild-type mice. In adrenalectomized kl/kl mice, spironolactone treatment still significantly ameliorated aortic osteoinductive reprogramming. Our findings suggest that VSMCs express aldosterone synthase, which is up-regulated by phosphate-induced disruption of APEX1-dependent gene suppression. Vascular CYP11B2 may contribute to stimulation of VSMCs osteo-/chondrogenic transformation during hyperphosphatemia.

In order to analyze the softening behavior of 22MnB5 steel and further predict the constitutive relationship during hot sheet metal forming, a series of isothermal hot compression tests were conducted at the temperature range of 800–950 °C and strain rate range of 0.01–0.8 s−1 on BAEHR 805 A/D thermo-mechanical simulator system. Based on the friction corrected flow curves, the characteristic strain and stress of dynamic recrystallization (DRX) were derived from the Kocks-Mecking plots and expressed as a function of Zener-Hollomon parameter. Moreover, a physical constitutive model considering work hardening (WH), dynamic recovery (DRV) and DRX as well as corresponding JMAK-type DRX kinetics were developed. The results showed that the established physical equations can accurately predict the flow behavior with a correlation coefficient of 0.997 and average absolute relative error of 3.89%. Optical observation of the microstructure after hot compression revealed that the established DRX kinetics accurately reflects the reality, and then a Zener-Hollomon parameter dependent dynamic recrystallized grain size model was developed. Furthermore, EBSD analysis was carried out to study the effect of deformation conditions on martensite morphology and the results show that a lower temperature and higher strain rate lead to a finer martensite packet while the martensite block width becomes larger under the higher strain rate. Keywords: Constitutive model, Dynamic recrystallization, Martensite morphology

In the last decade, additive manufacturing technologies like laser powder bed fusion (LPBF) have emerged strongly. However, the process characteristics involving layer-wise build-up of the part and the occurring high, directional thermal gradient result in significant changes of the microstructure and the related properties compared to traditionally fabricated materials. This study presents the influence of the build direction (BD) on the microstructure and resulting properties of a novel austenitic Fe-30Mn-1C-0.02S alloy processed via LPBF. The fabricated samples display a {011} texture in BD which was detected by electron backscatter diffraction. Furthermore, isolated binding defects could be observed between the layers. Quasi-static tensile and compression tests displayed that the yield, ultimate tensile as well as the compressive yield strength are significantly higher for samples which were built with their longitudinal axis perpendicular to BD compared to their parallel counterparts. This was predominantly ascribed to the less severe effects of the sharp-edged binding defects loaded perpendicular to BD. Additionally, a change of the Young’s modulus in dependence of BD could be demonstrated, which is explained by the respective texture. Potentiodynamic polarization tests conducted in a simulated body fluid revealed only slight differences of the corrosion properties in dependence of the build design.

Vitamin D testing and treatment is a subject of controversial scientific discussions, and it is challenging to navigate through the expanding vitamin D literature with heterogeneous and partially opposed opinions and recommendations. In this narrative review, we aim to provide an update on vitamin D guidelines and the current evidence on the role of vitamin D for human health with its subsequent implications for patient care and public health issues. Vitamin D is critical for bone and mineral metabolism, and it is established that vitamin D deficiency can cause rickets and osteomalacia. While many guidelines recommend target serum 25-hydroxyvitamin D (25[OH]D) concentrations of ≥50 nmol/L (20 ng/mL), the minimum consensus in the scientific community is that serum 25(OH)D concentrations below 25–30 nmol/L (10–12 ng/mL) must be prevented and treated. Using this latter threshold of serum 25(OH)D concentrations, it has been documented that there is a high worldwide prevalence of vitamin D deficiency that may require public health actions such as vitamin D food fortification. On the other hand, there is also reason for concern that an exploding rate of vitamin D testing and supplementation increases costs and might potentially be harmful. In the scientific debate on vitamin D, we should consider that nutrient trials differ from drug trials and that apart from the opposed positions regarding indications for vitamin D treatment we still have to better characterize the precise role of vitamin D for human health.

BackgroundMarinobufagenin (MBG) is an endogenous cardiotonic steroid (CTS) that inhibits the Na+/K+-ATPase. Human MBG is significantly increased in end-stage renal disease and immunization against MBG attenuates cardiovascular fibrosis in a rat model of uremic cardiomyopathy. Mineralocorticoid antagonists (MRA) block MBG binding sites and decrease proteinuria in chronic kidney disease (CKD) patients. We therefore aimed to investigate the association of MBG and albuminuria, as a marker of renal damage, as well as MBG and decline of glomerular filtration rate (GFR).MethodsThe Graz endocrine causes of hypertension (GECOH) study is a single center study of adults routinely referred for screening of endocrine hypertension. Plasma MBG was measured by an enzyme-linked immunoassay, and in a post-hoc analysis, follow-up creatinine levels were obtained. Patients with proteinuria >3.5g/day at baseline were excluded from further evaluation.ResultsWe measured MBG concentrations in 40 hypertensive subjects and excluded one patient due to pre-existing proteinuria. Plasma MBG was significantly correlated with albuminuria (Spearman ρ = .357; p = .028) and proteinuria (ρ = .336; p = .039). In linear regression analysis, the association remained significant after adjustment for age, sex, and BMI (β = .306; p = .036), and for mean systolic blood pressure (β = .352; p = .034). In follow-up analyses (N = 30), MBG was significantly associated with decline in GFR after adjustment for time-to-follow-up (β = -.374; p = .042).ConclusionThe findings suggest that MBG plasma concentrations were associated with albuminuria as well as decline in kidney function. Whether MBG predicts hard renal endpoints warrants further investigations.

AIMS OF THE STUDY Allostatic load (AL), as a marker of cumulative stress, is associated with higher morbidity and mortality, and reduced health-related quality of life (HrQoL) in healthy adults. In patients with hypertension, AL and its association with HrQoL have not been investigated. Therefore, this study aimed to (1) explore AL in a cohort of hypertensive patients and to (2) determine its association with HrQoL, while controlling for other health-related variables. METHODS Cross-sectional data from the Styrian Hypertension Study were analysed and included 126 participants (50% female) with a history of arterial hypertension; the mean age was 60.9 years (standard deviation 9.9). AL was derived from a set of 10 biomarkers including neurophysiological, neuroendocrine, metabolic, cardiovascular and inflammatory parameters. The 36-Item Short Form Health Survey (SF-36) was administered for assessment of HrQoL. Additional health-related variables included sociodemographic data, lifestyle factors and comorbidities. RESULTS Calculation of AL resulted in sum scores based on 10 binary variables, which were used to categorise patients as either “low AL” (

Vitamin D deficiency can lead to musculoskeletal diseases such as rickets and osteomalacia, but vitamin D supplementation may also prevent extraskeletal diseases such as respiratory tract infections, asthma exacerbations, pregnancy complications and premature deaths. Vitamin D has a unique metabolism as it is mainly obtained through synthesis in the skin under the influence of sunlight (i.e., ultraviolet-B radiation) whereas intake by nutrition traditionally plays a relatively minor role. Dietary guidelines for vitamin D are based on a consensus that serum 25-hydroxyvitamin D (25[OH]D) concentrations are used to assess vitamin D status, with the recommended target concentrations ranging from ≥25 to ≥50 nmol/L (≥10–≥20 ng/mL), corresponding to a daily vitamin D intake of 10 to 20 μg (400–800 international units). Most populations fail to meet these recommended dietary vitamin D requirements. In Europe, 25(OH)D concentrations

BackgroundLow 25‐hydroxyvitamin D levels are associated with an increased risk of cardiovascular events, but the effect of vitamin D supplementation on markers of vascular function associated with major adverse cardiovascular events is unclear. Methods and ResultsWe conducted a systematic review and individual participant meta‐analysis to examine the effect of vitamin D supplementation on flow‐mediated dilatation of the brachial artery, pulse wave velocity, augmentation index, central blood pressure, microvascular function, and reactive hyperemia index. MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, and http://www.ClinicalTrials.gov were searched until the end of 2016 without language restrictions. Placebo‐controlled randomized trials of at least 4 weeks duration were included. Individual participant data were sought from investigators on included trials. Trial‐level meta‐analysis was performed using random‐effects models; individual participant meta‐analyses used a 2‐stage analytic strategy, examining effects in prespecified subgroups. 31 trials (2751 participants) were included; 29 trials (2641 participants) contributed data to trial‐level meta‐analysis, and 24 trials (2051 participants) contributed to individual‐participant analyses. Vitamin D3 daily dose equivalents ranged from 900 to 5000 IU; duration was 4 weeks to 12 months. Trial‐level meta‐analysis showed no significant effect of supplementation on macrovascular measures (flow‐mediated dilatation, 0.37% [95% confidence interval, −0.23 to 0.97]; carotid‐femoral pulse wave velocity, 0.00 m/s [95% confidence interval, −0.36 to 0.37]); similar results were obtained from individual participant data. Microvascular function showed a modest improvement in trial‐level data only. No consistent benefit was observed in subgroup analyses or between different vitamin D analogues. ConclusionsVitamin D supplementation had no significant effect on most markers of vascular function in this analysis.

INTRODUCTION:Immunotherapy is a well-established treatment option in patients with metastatic melanoma. However, biomarkers that can be used to predict a response in these patients have not yet been found, putting patients at risk of severe side effects. METHODS:In this retrospective analysis, we investigated the association between the body mass index and ipilimumab treatment response in patients with metastatic melanoma. Patients with metastatic melanoma who received a monotherapy of up to 4 doses of ipilimumab (3 mg/kg) every 3 weeks from 2011 to 2014 in three major hospitals in Austria were included. Patients were classified into two groups: normal group (BMI

Objective. 1,25-Dihydroxyvitamin D (1,25([OH]2D) is considered to be a negative endogenous regulator of the renin-angiotensin-aldosterone system (RAAS), but the effect of vitamin D supplementation on the RAAS is inconclusive. Design. In this prespecified secondary analysis of a randomized controlled trial, we assessed in 165 patients with heart failure (vitamin D group: n=83; placebo group: n=82) the effect of three years of vitamin D supplementation with 4000 IU daily on parameters of the RAAS (renin and aldosterone) and on circulating 1,25(OH)2D, plasma phosphate, and fibroblast growth factor (FGF)-23. We assessed age- and baseline-adjusted between-group differences at study termination. Results. Almost all patients were under treatment with beta-blockers, inhibitors of the RAAS, and diuretics. Initially, the frequency of concentrations above the laboratory-specific reference range (renin: >23.9 mIU/L; aldosterone: >232 ng/L) in the vitamin D and placebo group was 87.7% and 92.7%, respectively (renin), and 24.1% and 32.5%, respectively (aldosterone). Vitamin D increased adjusted 1,25(OH)2D concentrations significantly (mean treatment effect and 95% CI: 18.3 pmol/L,7.3 to 29.3 pmol/L; P