It has been proposed that recent cultural inventions such as symbolic arithmetic recycle evolutionary older neural mechanisms. A central assumption of this hypothesis is that the degree to which a pre-existing mechanism is recycled depends upon the degree of similarity between its initial function and the novel task. To test this assumption, we investigated whether the brain region involved in magnitude comparison in the intraparietal sulcus (IPS), localized by a numerosity comparison task, is recruited to a greater degree by arithmetic problems that involve number comparison (single-digit subtractions) than by problems that involve retrieving facts from memory (single-digit multiplications). Our results confirmed that subtractions are associated with greater activity in the IPS than multiplications, whereas multiplications elicit greater activity than subtractions in regions involved in verbal processing including the middle temporal gyrus and inferior frontal gyrus that were localized by a phonological processing task. Pattern analyses further indicated that the neural mechanisms more active for subtraction than multiplication in the IPS overlap with those involved in numerosity comparison, and that the strength of this overlap predicts inter-individual performance in the subtraction task. These findings provide novel evidence that elementary arithmetic relies on the co-option of evolutionary older neural circuits.

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Renal glucose reabsorption was measured with the stepped hyperglycemic clamp in 15 subjects with type 2 diabetes mellitus (T2DM) and 15 without diabetes after 2 days and after more chronic (14 days) treatment with empagliflozin. Patients with T2DM had significantly greater maximal renal glucose transport (Tm) compared with subjects without diabetes at baseline (459 ± 53 vs. 337 ± 25 mg/min; < 0.05). Empagliflozin treatment for 48 h reduced the Tm in both individuals with and without diabetes by 44 ± 7 and 53 ± 6%, respectively (both < 0.001). Tm was further reduced by empagliflozin in both groups on day 14 (by 65 ± 5 and 75 ± 3%, respectively). Empagliflozin reduced the plasma glucose concentration threshold for glucose spillage in the urine similarly in individuals with T2DM and without diabetes to <40 mg/dL, which is well below the normal fasting plasma glucose concentration. In summary, sodium-glucose transporter-2 inhibition with empagliflozin reduces both Tm and threshold for glucose spillage in the urine in patients with T2DM and those without diabetes.

Thiazolidinediones (TZDs) are insulin-sensitizing antidiabetes agents that act through the peroxisome proliferator-activated receptor-γ to cause a durable improvement in glycemic control in patients with type 2 diabetes mellitus. Although less well recognized, TZDs also exert a protective effect on β-cell function. In addition to their beneficial effects on glucose homeostasis, TZDs-especially pioglitazone-exert a number of other pleiotropic effects that make them ideal agents as monotherapy or in combination with other oral agents, glucagon-like peptide-1 analogs, or insulin. Pioglitazone improves endothelial dysfunction, reduces blood pressure, corrects diabetic dyslipidemia, and reduces circulating levels of inflammatory cytokines and prothrombotic factors. Pioglitazone also redistributes fat and toxic lipid metabolites in muscle, liver, β cells, and arteries, and deposits the fat in subcutaneous adipocytes where it cannot exert its lipotoxic effects. Consistent with these antiatherogenic effects, pioglitazone reduced major adverse cardiac event endpoints (ie, mortality, myocardial infarction, and stroke) in the Prospective Pioglitazone Clinical Trial in Macrovascular Events and in a meta-analysis of all other published pioglitazone trials. Pioglitazone also mobilizes fat out of the liver, improving liver function and histologic abnormalities in patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Pioglitazone also reduces proteinuria, all-cause mortality, and cardiovascular events in patients with type 2 diabetes mellitus with a reduced glomerular filtration rate. These benefits must be weighed against the side effects of the drug, including weight gain, fluid retention, atypical fractures, and, possibly, bladder cancer. When low doses of pioglitazone are used (eg, 7.5-30 mg/d) with gradual titration, and physician recognition of the potential side effects are applied, the risk-to-benefit ratio is very favorable. Despite having similar effects on glycemic control, pioglitazone and rosiglitazone appear to have different effects on cardiovascular outcomes. Rosiglitazone has been associated with an increased risk of myocardial infarction, and its use in the United States is restricted because of cardiovascular safety concerns.