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.

Health profiles of spouse caregivers: The role of active coping and the risk for developing prolonged grief symptoms

STUDY AIMS

1) To characterize distinct profiles of cancer caregivers' physical and mental health during the end-of-life caregiving period; 2) to identify the background and antecedent factors associated with the distinct profiles of caregivers; 3) to determine the relevance of caregiver profiles to the risk for developing prolonged grief symptoms.

DESIGN & METHODS

This study was a secondary analysis of spouses/partners (n = 198) who participated in the Cancer Caregiver Study. Latent profile mixture modeling was used to characterize caregiver health profiles from data collected prior to their spouse's death. Regression analyses were used to determine the impact of caregiver health profiles on the risk of developing prolonged grief symptoms (PG-13 scale).

RESULTS

Two health profiles were identified, one of which was comprised of a minority of caregivers (n = 49; 25%) who exhibited higher anxiety and depressive symptoms, greater health impact from caregiving, more self-reported health problems, and greater difficulty meeting physical demands of daily activities. Caregivers who were observed in this poorer health profile had significantly lower levels of active coping (p < 0.001) in adjusted models. Additionally, according to subsequent bereavement data, caregivers' preloss health profile was a significant predictor of developing prolonged grief symptoms (p = 0.018), controlling for caregivers' age (p = 0.040) and amount of active coping (p = 0.049), and there was a mediating effect of caregiver health on the relationship between active coping and prolonged grief symptoms.

CONCLUSIONS

Caregiving and bereavement should not be considered separately; caregivers adapt to bereavement with the resources and coping attained throughout the life course, culminating in the experience of providing end-of-life care. Interventions aimed at supporting caregivers and bereaved persons should focus on maintaining physical and mental health during stressful life transitions, and especially during the period in which they are providing care to a spouse at end-of-life.

Dual-Process Bereavement Group Intervention (DPBGI) for Widowed Older Adults

BACKGROUND AND OBJECTIVES

To examine the primary and secondary outcomes of a theory-driven group bereavement intervention for widowed older adults through a cluster-randomized controlled trial.

RESEARCH DESIGNS AND METHODS

Twelve community centers providing health and social services for elderly people were randomly assigned to the experimental condition, the dual-process bereavement group intervention-Chinese (DPBGI-C) and to the control condition, the loss-oriented bereavement group intervention-Chinese (LOBGI-C). Both interventions comprised weekly, 2-hr sessions for 7 weeks followed by a 4-hr outing in the eighth week. Of 215 widowed older adults contacted and assessed, 125 eligible participants were interviewed three times-preintervention, postintervention, and at a 16-week follow-up-to assess complicated grief symptoms, anxiety, depression, loneliness, and social support.

RESULTS

Using intention-to-treat analysis, both interventions produced improvements in grief, depression, and social support, but effect sizes were larger with the DPBGI-C. The participants in the DPBGI-C condition also reported reduced anxiety, emotional loneliness, and social loneliness, whereas those in the LOBGI-C condition did not. There were interactions between intervention type and time with respect to grief, anxiety, emotional loneliness, and social loneliness.

DISCUSSION AND IMPLICATIONS

Although traditional LOBGI-C can help to reduce grief and depression in bereaved older adults, the DPBGI-C was found to be superior as it had a greater and more extensive impact on outcomes. This is the first study of the effectiveness of this evidence-based, theory-driven intervention for widowed Chinese older adults and has implications for theory building and practice.

Cancer Caregivers' Preparedness for Loss and Bereavement Outcomes: Do Preloss Caregiver Attributes Matter?

Past studies examining the relationship between preparedness for loss and bereavement outcomes among caregivers of spouses/partners with life-limiting illness did not adequately account for preloss caregiver attributes that could potentially confound the relationship. Using a sample of spouse/partner cancer caregivers (N = 226), we examined how preloss caregiver attributes were associated with how prepared one felt for loss and their role in the relationship between preparedness and later bereavement outcomes. Nearly half reported they were not emotionally prepared, and 35% were not prepared for the practical challenges associated with the loss. Although attributes such as depression, anxiety, competence in daily activities, and financial adequacy were associated with both preparedness and bereavement outcomes, regression analyses revealed that preparedness remained the strongest predictor in all models. We suggest that early interventions enhancing caregivers' preparedness for loss may hold considerable promise for improved bereavement outcome.

Communication of emotion in home hospice cancer care: Implications for spouse caregiver depression into bereavement

OBJECTIVE

Family caregivers of cancer hospice patients likely benefit from clinician provision of verbal support and from expression of positive emotions. Our aim was to identify the effects of hospice nurse supportive communication as well as caregiver-nurse exchange of positive emotions on family caregiver depression during bereavement.

METHODS

This prospective, observational longitudinal study included hospice nurses (N = 58) and family caregivers of cancer patients (N = 101) recruited from 10 hospice agencies in the United States. Digitally recorded nurse home visit conversations were coded using Roter interaction analysis system to capture emotion-focused caregiver-nurse communication and supportive nurse responses. Caregivers completed the Hospital Anxiety and Depression Scale Anxiety Subscale and Geriatric Depression Scale-Short Form at study enrollment and at 2, 6, and 12 months after patient death.

RESULTS

Caregivers had moderate levels of depression at study enrollment and throughout bereavement. Multilevel modeling revealed that caregiver positive emotion communication and nurse emotional response communication are associated with caregiver depression in bereavement. There was no significant association between caregiver distress communication and depression in bereavement.

CONCLUSIONS

This is the first study to demonstrate that communication demonstrating emotional expression between cancer spouse caregivers and nurses during home hospice may have implications for caregiver depression up to a year after patient death. Our findings may help identify caregivers who may be coping well in the short term but may struggle more over time.

Effectiveness of a minimal resource fracture liaison service

PURPOSE

The purpose of this study was to investigate if a 2-year intervention with a minimal resource fracture liaison service (FLS) was associated with increased investigation and medical treatment and if treatment was related to reduced re-fracture risk.

METHODS

The FLS started in 2013 using existing secretaries (without an FLS coordinator) at the emergency department and orthopaedic wards to identify risk patients. All patients older than 50 years of age with a fractured hip, vertebra, shoulder, wrist or pelvis were followed during 2013-2014 (n = 2713) and compared with their historic counterparts in 2011-2012 (n = 2616) at the same hospital. Re-fractures were X-ray verified. A time-dependent adjusted (for age, sex, previous fracture, index fracture type, prevalent treatment, comorbidity and secondary osteoporosis) Cox model was used.

RESULTS

The minimal resource FLS increased the proportion of DXA-investigated patients after fracture from 7.6 to 39.6 % (p < 0.001) and the treatment rate after fracture from 12.6 to 31.8 %, which is well in line with FLS types using the conventional coordinator model. Treated patients had a 51 % lower risk of any re-fracture than untreated patients (HR 0.49, 95 % CI 0.37-0.65 p < 0.001).

CONCLUSIONS

We found that our minimal resource FLS was effective in increasing investigation and treatment, in line with conventional coordinator-based services, and that treated patients had a 51 % reduced risk of new fractures, indicating that also non-coordinator based fracture liaison services can improve secondary prevention of fractures.

Emotional disclosure in home hospice cancer care: Implications for spouse caregiver bereavement

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Background: Evidence shows the benefit of positive and negative emotional disclosure for family caregivers (CG), but little is known about the impact of emotional disclosure at end of life. We assessed the effect of CG and hospice nurse disclosure during home visits on CG anxiety and depression in bereavement. Methods: As part of a larger study, nurse visits to 95 spouse CGs of cancer home hospice patients were audio recorded. An adapted Roter Interaction Analysis System was used to identify emotional disclosure: CG and nurse positive emotion (humor, gratitude), CG distress, and nurse emotional response (reassurance, validation). CGs completed demographics at hospice enrollment, and HADS anxiety scale, and Geriatric Depression Scale (GDS) at enrollment, and 2, 6 and 12 months after patient death. Growth curve analysis was conducted to predict HADS and GDS trajectories, controlling for CG gender, total talk, anxiety and depression at enrollment. Results: Average spouse CG age was 65; 60% were female and 98% were white. There were no GDS effects for CG expression of distress or nurse emotional response. Higher CG positive emotion talk predicted higher GDS at 2 months (B = .18, p < .01), but a significant decline of GDS over time (B = -.08, p = .03). There were no effects for CG emotional disclosure on anxiety. However, more nurse emotional response predicted lower anxiety at 2 months (B = -.10, p = .02) which did not significantly change over time. More nurse positive emotion did not impact anxiety at 2 months, but predicted lower anxiety over time (B = -.04, p = .04). Conclusions: Emotional disclosure during cancer hospice visits was associated with spouse CG bereavement trajectories. CG positive emotion talk may signal increased potential for depression early in bereavement, but appears to lessen over time. CGs who express more positive emotion, which includes humor, gratitude and savoring the moment, may be more sensitive to loss, but appear to recover in time. Nurse expression of reassurance and validation, and of positive emotions seems to be effective in addressing and normalizing CG anxiety during bereavement. These findings have potential implications for communication interventions.

Spouse cancer caregivers' burden and distress at entry to home hospice: The role of relationship quality

High-quality relationships may be protective for family caregivers. This study focuses on relationship quality categories (supportive and ambivalent) in spouse caregivers in cancer home hospice. The goals of this article are to, first, describe relationship quality categories among end-of-life caregivers and, second, test the effects of relationship quality categories on caregiver burden and distress within a stress process model. Using questionnaire data collected at entry to home hospice, we found relationship quality categories were proportionally similar to those seen in noncaregiver older adults. Relationship quality significantly predicted caregiver burden, which completely mediated the relationship between caregiver relationship quality and distress. Caregivers whose social contexts place them at risk for greater distress may benefit from increased clinical attention or intervention.

An inertial sensor-based system can objectively assess diagnostic anaesthesia of the equine foot

REASONS FOR PERFORMING STUDY

In order for changes in lameness to be accurately and repeatably detected and recorded during diagnostic investigations, an objective measure of lameness is required.

OBJECTIVES

To ascertain whether an inertial sensor-based system can distinguish between a positive and negative response to diagnostic anaesthesia of the foot and objectively assess the effect of a positive response on the trot.

STUDY DESIGN

Restrospective clinical study.

METHODS

Data obtained during lameness investigations undertaken between August 2011 and December 2012 in which either a palmar digital or abaxial sesamoid nerve block was performed were retrospectively reviewed. Response to diagnostic anaesthesia was categorised as positive (n = 14) or negative (n = 9) by one of 2 evaluators before analysis of kinematic data (i.e. blinded). Changes in maximum and minimum head difference (ΔHDMax and ΔHDMin) and change in head movement asymmetry/change in pelvic movement asymmetry (ΔHMA/PMA, measure of asymmetry) allocated to each limb were calculated. A Kruskal-Wallis one way analysis of variance on ranks was performed. Receiver operating characteristic (ROC) curves were generated for ΔHDMax, ΔHDMin and ΔHMA for the blocked limb to identify cut-off values to distinguish positive and negative responses to the block.

RESULTS

Median ΔHDMax and ΔHDMin were significantly greater after a positive response to diagnostic anaesthesia (P<0.01). Change in head movement asymmetry allocated to the blocked limb and contralateral forelimb and ΔPMA allocated to the contralateral hindlimb were significantly greater in the positive response group (P<0.05). Change in head movement asymmetry allocated to the blocked limb and ΔHDMax and ΔHDMin are useful diagnostic tests for identifying positive response to anaesthesia (area under the curve = 0.98, 0.83 and 0.96 respectively).

CONCLUSIONS

An inertial sensor-based system can identify a positive response to diagnostic anaesthesia of the foot. Symmetry of movement allocated to the blocked limb, contralateral forelimb and contralateral hindlimb significantly improve, and head movement significantly decreases in horses with a positive response to the block. Cut-off values for a positive response have been identified with good sensitivity and specificity. Forelimb lameness significantly affects contralateral hindlimb movement, which has implications for the investigation of multi-limb lameness.

Missed Opportunity: Hospice Care and the Family

A typical mission statement of hospice services is to provide quality, compassionate care to those with terminal illness and to support families through caregiving and bereavement. This study explored the ways that bereavement needs of caregivers, either predeath or postdeath of their spouse/partner, were addressed using qualitative retrospective phone interviews with 19 caregivers whose spouse/partner was enrolled in hospice care for cancer. Overall, participants expressed high satisfaction with hospice care, most often noting a high satisfaction with the quality of care provided to their spouse/partner. During the predeath phase, caregivers recalled being so focused on their spouse/partner's needs that they rarely spoke with hospice staff about their own personal needs and emotions. Participants said that bereavement counseling occurred primarily after the death of the spouse/partner, in the form of generic pamphlets or phone calls from someone they had not met during prior interactions with hospice staff. These findings suggest that caregivers' high satisfaction with hospice may be more associated with the quality of care provided to the spouse/partner than with bereavement support they received. Our findings illustrated a potential missed opportunity for hospices to address the family-oriented goals that are commonly put forward in hospice mission statements.

Coping processes among bereaved spouses

The authors investigated if an intervention based on the dual process model (vs. traditional bereavement support) enhanced oscillation between loss- (LO) and restoration-oriented (RO) coping of recently bereaved (2-6 months) spouses/partners. Participants were followed over 12 months. The authors found an increased emphasis over time on RO coping, particularly for women and those who were younger; however, no treatment effect was detected. Although patterns in the data are consistent with the model, the authors conclude that it is difficult for interventions to modify LO, RO, and oscillation unless there is sufficient intervention dosage and tailored to those exclusively engaged in one process.

Friend and family contact and support in early widowhood

OBJECTIVES

This study explored the relative contributions of friends and family to the social and emotional well-being of women and men in the first 2-6 months following the death of their spouse or partner.

METHODS

Three hundred and twenty-eight widowed men (39%) and women aged 50 and older completed self-administered questionnaires that included measures of contact and satisfaction with friends and family, as well as measures of affective (i.e., grief and depression) and self-evaluative (i.e., coping self-efficacy, mastery, self-esteem) responses to loss.

RESULTS

Regression analyses supported the positive features of social support and interaction but particularly highlight the role of friends: ease of contact and satisfaction with friendship support were associated with more positive self-evaluative aspects of loss; greater frequency of friendship help was associated with more negative affective reactions, whereas higher satisfaction with friendship support was associated with more positive affective reactions.

DISCUSSION

These analyses support the voluntary and socializing functions of friendship and social support, bolstering individuals during stressful life transitions, advancing our understanding of the underexamined and particularly distinct functions of friendship in the early phases of spousal loss.

Feeling lonely versus being alone: loneliness and social support among recently bereaved persons

OBJECTIVES

Despite increases in social support following widowhood, loneliness is among the most frequently reported challenges of bereavement. This analysis explores the dynamic relationship between social support and loneliness among recently bereaved older adults.

METHODS

Using longitudinal data from "Living After Loss" (n = 328), latent growth curve modeling was used to estimate changes in loneliness and social support during the first year and a half of bereavement among older adults aged 50+.

RESULTS

Both loneliness and social support declined over the first year and a half of bereavement. Greater social support was associated with lower levels of loneliness overall, but the receipt of social support did not modify one's expression of loneliness over time. Loneliness was more highly correlated with support from friends than family. Together, social support from both friends and family accounted for 36% of the total variance in loneliness.

DISCUSSION

There is conceptual and empirical overlap between the concepts of loneliness and social support, but results suggest that loneliness following widowhood cannot be remedied by interventions aimed only at increasing social support. Social support, especially that from friends, appears to be most effective if it is readily accessible and allows the newly bereaved an opportunity to express him/herself.

An Evaluation of the Living After Loss Intervention - Part 1: Do Bereavement-Related Outcomes Vary by the Content of Support Groups?

This article explores whether the substantive content and specific topics addressed during a 14-week support group can alter the bereavement-related outcomes of widowed older adults over time. It draws on data from the Living After Loss study, which developed a novel support group based on the Dual Process Model of bereavement and provides empirical evidence tracking the longitudinal outcomes of older bereaved spouses. Findings suggest that unless the content is universally relevant, the messaging and topics addressed during the support group do not alter the bereavement-related outcomes of widowed persons over time.

An Evaluation of the Living After Loss Intervention - Part 2: Do Bereavement-Related Outcomes Vary by the Dynamics of Support Groups?

Group-based interventions for recently bereaved spouses may provide support and friendship through the commonality of experiences that are shared among the members of the group. This study compares the experiences and characteristics of persons in 35 different support groups from the Living After Loss (LAL) study, with particular emphasis on the question: Does the chemistry of the group affect the longer term adjustment outcomes associated with bereavement? Results suggest that, perhaps, those groups that foster the greatest sense of mutual support and have the most effective group leaders may be associated with more favourable bereavement-related outcome, especially stress related growth. Challenges associated with evaluating the effectiveness of group-based interventions are also discussed.

Grief, depressive symptoms, and physical health among recently bereaved spouses

PURPOSE

 Widowhood is among the most distressing of all life events, resulting in both mental and physical health declines. This paper explores the dynamic relationship between physical health and psychological well-being among recently bereaved spouses. 

DESIGN AND METHODS

 Using a sample of 328 bereaved persons who participated in the "Living After Loss" study, we modeled trends in physical health, somatic symptoms, and psychological well-being over the first year and a half of widowhood. The primary focus is whether physical health at the time of widowhood modifies psychological well-being over time. 

RESULTS

 There were considerable somatic symptoms during the earliest months of bereavement but no major health declines over the first year and half of bereavement. Those in poor health had initially higher levels of grief and depressive symptoms, but the trajectories or changes over time were similar regardless of health status. Those with poor health at the time of widowhood had significantly higher risks of complicated grief and major depression disorder. 

IMPLICATIONS

 Bereavement requires physical and emotional adjustment, but the psychological trajectory of bereavement may be somewhat universal. Bereavement support ought to include a focus on self-care and health promotion in addition to emotional support, especially because those with poor health initially may be most susceptible to prolonged and intense clinical distress.

Experiences and early coping of bereaved spouses/partners in an intervention based on the dual process model (dpm)

This study was designed to test the effectiveness of the Dual Process Model (DPM) of coping with bereavement. The sample consisted of 298 recently widowed women (61%) and men age 50+ who participated in 14 weekly intervention sessions and also completed before (O1) and after (O2) self-administered questionnaires. While the study also includes two additional follow-up assessments (O3 and O4) that cover up to 14-16 months bereaved, this article examines only O1 and O2 assessments. Based on random assignment, 128 persons attended traditional grief groups that focused on loss-orientation (LO) in the model and 170 persons participated in groups receiving both the LO and restoration-orientation (RO) coping (learning daily life skills). As expected, participants in DPM groups showed slightly higher use of RO coping initially, but compared with LO group participants they improved at similar levels and reported similar high degrees of satisfaction with their participation (i.e., having their needs met and 98-100% indicating they were glad they participated. Even though DPM participants had six fewer LO sessions, they showed similar levels of LO improvement. Qualitative data indicate that the RO component of the DPM might be more effective if it is tailored and delivered individually.

A Tale of Two Counties:Bereavement in Socio-Demographically Diverse Places

The "Living After Loss" study was designed to test the effectiveness of the dual process model (DPM) of coping with bereavement. In order to obtain a larger and more diverse sample we studied 328 recently widowed men and women (61%) age 50+ in two counties, Salt Lake (n=197) and San Francisco (n=131) in two states, Utah and California. This paper does not report on the effects of the intervention but focuses on a comparison of the bereaved spouses/partners in these two cites. First, the only socio-demographic differences we found between those in SF and SL were that those in San Francisco were more racially, ethnically and religiously diverse, higher in education, had slightly fewer years in their relationship to the deceased and were two weeks longer in their grief process. Second, there were far more similarities than differences between SF and SL regarding nearly all of the study variables. Third, we found that those in SF had more positive qualitative features in their friendship support networks and that for bereaved in both counties, we found strong associations with having highly supportive friend-based networks and more positive bereavement adjustments (especially experiencing lower levels of loneliness and depression). Limitations and suggestions for future research are described.

Effects of teacher attention on study behavior

The effects of contingent teacher attention on study behavior were investigated. Individual rates of study were recorded for one first-grade and five third-grade pupils who had high rates of disruptive or dawdling behavior. A reinforcement period (in which teacher attention followed study behavior and non-study behaviors were ignored) resulted in sharply increased study rates. A brief reversal of the contingency (attention occurred only after periods of non-study behavior) again produced low rates of study. Reinstatement of teacher attention as reinforcement for study once again markedly increased study behavior. Follow-up observations indicated that the higher study rates were maintained after the formal program terminated.

Sampling, recruitment, and retention in a bereavement intervention study: experiences from the Living After Loss Project

This article reports on the sampling and recruitment challenges, as well as the strategies used to address them in the Living After Loss (LAL) project, a bereavement intervention study conducted in Salt Lake City and San Francisco comparing two 14-week group conditions with follow-up. We encountered three major challenges: 1) difficulty determining eligibility for some potential participants who were contacted, 2) locating and recruiting nonwhites, and 3) unavailable phone numbers for approximately one-third of those we attempted to contact. Despite these challenges, we achieved a 42% response rate with a sample size of 328 participants comprising 15% nonwhite. Eighty-five percent of the participants completed all of the follow-up data points. Leading factors in participants' decisions to join and remain in the study were 1) opportunities to obtain help and support, 2) to potentially help other bereaved individuals, 3) to contribute to research, and 4) their on-going interactions with a professional, empathetic, and culturally sensitive project staff. Effectively focusing recruitment efforts and carefully and systematically training research staff were among the most effective strategies we employed and therefore suggest for those planning similar investigations.

Stress-related growth among the recently bereaved

Although stress-related growth (SRG), or a personal transformation beyond adaptation, can be an outcome for some individuals after a traumatic life experience like spouse or partner loss, it is often assumed that some time needs to pass before this happens. This study reports on early experiences of SRG relatively soon after the loss of a spouse or partner in mid and later life. Self-administered questionnaires were completed by 292 recently bereaved (2-6 months) partners, aged 50+, as part of the Living After Loss study conducted in Salt Lake City and San Francisco. Substantial variability in SRG was observed where 21% scored > or =1 SD above and approximately 18% scored > or =1 SD below the sample mean of 17.2 (SD = 7.0). Regression analyses revealed that SRG was more likely for those who had expected their partners' deaths, who were more religious and who engaged in loss- and restoration-oriented coping processes, and was independent of grief levels. Findings suggest that some individuals drew upon their religious beliefs as a way to find meaning and make sense of what happened as they rebuilt their 'assumptive world'. Also, those who anticipated their partner's death could have had more opportunity to cognitively process the loss, address the challenges of widowed life and learn new skills and discover previously unrecognized strengths.

Music thanatology: prescriptive harp music as palliative care for the dying patient

Music thanatology represents an emerging area in which the raw materials of music, usually harp and/or voice, assist and comfort the dying patient. During prescriptive "music vigils, " the clinician-musician carefully observes physiological changes, cues, and breathing patterns, thereby synchronizing the music to reflect or support the patient's physiology and overall condition. Using data collected from 65 patients, this study was designed to assess the effectiveness of prescriptive harp music on selected palliative care outcomes using a sample of de-identified data forms from past music vigils. Patients were administered a 25- to 95-minute intervention of prescriptive harp music. Data collected included vital signs and observational indicators before (Ti) and after (T2) the vigil. Patients were more likely to experience decreased levels of agitation and wakefulness while also breathing more slowly and deeply with less effort at the conclusion of the music vigil. Results from this study suggest that a prescriptive vigil conducted by a trained music thanatologist could provide an effective form of palliative care for dying patients.

Approaches to enhance expression after adenovirus-mediated gene transfer to the carotid artery

The goal of this study was to enhance transgene expression after adenoviral-mediated gene transfer to the carotid artery. We used an adenoviral vector with a transgene that expresses beta-galactosidase, driven by the human cytomegalovirus (CMV) promoter/enhancer. The CMV promoter drives constitutive expression, and response elements within the enhancer allow inducible expression through binding of active transcription factors, such as cAMP response element binding protein (CREB) and nuclear factor kappa B (NFkappaB). Rings of rabbit carotid artery were incubated ex vivo with a replication-deficient adenovirus that expresses beta-galactosidase (AdCMV-betagal). Virus was removed from the medium, and forskolin or phorbol-12-myristate-13-acetate (PMA), which can induce activation of CREB or NFkappaB, respectively, were added to the medium. Pyrrolidine dithiocarbamate (PDTC) was used to inhibit activation of NFkappaB. Following incubation for 24 hours, beta-galactosidase activity was assessed by chemiluminescent reporter assay. Forskolin and PMA enhanced transgene expression in the carotid artery. Activity increased from 56+/-13 mU/mg protein (mean+/-SE) in rings of carotid treated with virus alone (10(9) pfu) to 159+/-23 mU/mg protein (P<0.05) in rings treated with forskolin, and to 189+/-40 mU/mg protein (P<0.05) in rings treated with PMA. Phorbol didecanoate, an inactive phorbol, did not affect expression of beta-galactosidase. After pre-incubation with PDTC prior to PMA, expression of beta-galactosidase was less than in rings incubated with PMA alone (29+/-11, P<0.05). Histochemical staining of carotid artery for beta-galactosidase demonstrated enhanced endothelial expression following administration of PMA. These findings suggest that expression after gene transfer to the carotid artery using an adenoviral vector with the CMV promoter/enhancer may be enhanced by PMA and forskolin, perhaps by activation of transcription factors.

Failure to transmit disease from gray tremor mutant mice

Mice homozygous for mutant alleles at the gray tremor (gt) locus develop a marked non-intention tremor beginning at 8 days of age. Most homozygous mice die by 3 months. Homozygotes exhibit intense vacuolation of the central nervous system gray matter and vacuolation and hypomyelination of some white matter tracts. Based on neuropathological similarities with scrapie, other investigators inoculated wild-type mice with gray tremor brain homogenates to test the hypothesis of transmissibility. Published reports indicated that spongiform encephalopathy (R. L. Sidman, H. C. Kinney, and H. O. Sweet, Proc. Natl. Acad. Sci. USA 82:253-257, 1985) and disease, including hind limb paralysis in NFS mice (P. M. Hoffman, R. G. Rohwer, C. MacAuley, J. A. Bilello, J. W. Hartley, and H. C. Morse III, Proc. Natl. Acad. Sci. USA 84:3866-3870, 1987), were transmitted by inoculation of gt/gt brain homogenates. In our hands, however, no NFS/NCr animals inoculated intracerebrally with gt/gt or +/+ brain preparations showed any signs of disease or pathological changes in the brain. Positive transmission by other investigators may reflect the microbiological status of their donor or recipient mice.

Understanding depression in bereaved older adults

Depression is a common outcome of spousal bereavement. Concurrent life events may contribute to the intensity of depression following spousal bereavement in older adults and, if not identified, may interfere with therapeutic plans for the management of depression. Taped interviews, conducted six times over two years, were analyzed for ten subjects, five whose depression scores were low, and five whose scores were high. In addition, a detailed case comparison analysis of two subjects was done. Four recurring types of life events, reported by the bereaved spouses, were illness (of self or others), deaths of family or friends, residential relocation, and changes in interpersonal relationships. Significantly depressed spouses were more likely to report these events. Implications for nursing practice and for integrating qualitative and quantitative research methods are addressed.

The spectrum of liver and spleen injuries in children: failure of the pediatric trauma score and clinical signs to predict isolated injuries

STUDY OBJECTIVES

To determine whether potentially life-threatening intra-abdominal injuries occur in the absence of multisystem trauma in children, and to determine the usefulness of physical examination and a pediatric triage score in the assessment of liver and spleen injuries in children.

DESIGN

Retrospective study.

SETTING

Admissions to a children's hospital from October 1982 through September 1989 who were found to have liver or spleen injuries. Seventy-seven patients were identified; 55 were male, 22 were female. Mean age was 9 years and 3 months (+/- 56 months) with a range of 22 months to 20 years, 4 months. Clinical signs were recorded and a Pediatric Trauma Score (PTS) and Injury Severity Score (ISS) were calculated for each patient.

MEASUREMENTS AND MAIN RESULTS

Fifty-four patients (70%) had a spleen injury, 18 (23%) had a liver injury, and five (7%) had both liver and spleen injuries. Patients were managed without surgery in 63 of 77 cases (82%); two died. Fifty-one of 77 patients (66%) received an ISS of 18 or less; 26 patients (34%) received a score of more than 18. Forty-four of the 51 patients (86%) with an ISS of 18 or less had a normal pulse (120 or less); 48 of the 51 (94%) had a normal systolic blood pressure (90 mm Hg or more). A strong negative correlation (r = -0.80; P = .001) was found between the two scores for children with multiple severe injuries (ISS of more than 18); there was poor correlation (r = -0.04; P greater than .05) between the two scores for isolated liver or spleen injury (ISS of 18 or less).

CONCLUSIONS

We conclude that liver or spleen damage may be present in children without other injuries and must be considered with a high index of suspicion, and that neither the initial clinical findings nor the PTS reliably predicts liver or spleen injuries in children with focal abdominal injuries.

Extracorporeal enzymatic heparin removal: use in a sheep dialysis model

Extracorporeal medical devices such as the hemodialyzer rely on systemic heparinization to prevent thrombus formation. Heparin, however, can lead to serious hemorrhagic complications. A blood filter containing immobilized heparinase, a heparin specific enzyme, was used to degrade heparin into small fragments which have significantly less anticoagulant activity than the parent compound. The heparinase filter was tested in the extracorporeal circuit during the hemodialysis of adult sheep. At a blood flow of 200 ml/min, the clearance of heparin varied from 50 to 70 ml/min (N = 16) depending on the amount of immobilized heparinase in the filter. Hemolysis was insignificant as measured by the animals' red cell counts, hematocrit, total hemoglobin and a plasma-free hemoglobin value of 89 +/- 33 mg/dl (N = 16) (less than 1% of the total hemoglobin). The white cell counts dropped to 47 +/- 7% (N = 16) of the initial value at 20 minutes and rebounded to 72 +/- 10% (N = 16) after one hour. The platelet counts decreased to 55 +/- 8% (N = 16) of the initial value after one hour. No change in heparin clearance was observed when reactors were used repeatedly in adult sheep over a 10 week period. The red cell counts, white cell counts, platelet counts, total hemoglobin and hematocrit did not change after 10 weeks of exposure to the device. These results suggest that with further study, heparinase may be useful in removing heparin used to anticoagulate blood in extracorporeal circuits.

Target tissue distribution of the proenkephalin peptides F, E, and B

The adrenal medulla is a rich source of endogenous opioid peptides. These peptides exist predominantly in the form of larger (25-34 amino acid long) enkephalin containing peptides, whose biological roles have yet to be elucidated. We report here the tissue binding distribution of three iodinated enkephalin containing peptides, Peptides F, E, and B, in rats, rabbits, and guinea pigs following intravenous injection. Each [125I]peptide has a unique distribution profile but all three are found to bind to the pituitary in each species of animal examined. A number of lines of evidence point toward the enkephalin containing peptides, Peptides F, E, and B, having physiological roles distinct from the enkephalins. The distribution profile of these [125I]peptides reported here gives insight into their potential effector sites.

Dynamic gravimetry in studying the adsorption of proteins onto metal surfaces: analysis and limitations

The paper describes the physical and mathematical fundamentals of dynamic gravimetry in liquid phase. First, a relation is developed to calculate the apparent weight of a vertical thin cylinder partially immersed Into a liquid. It emphasizes the magnitude of buoyancy forces and surface-tension forces (which act upon fine threads used to suspend a solid object completely immersed into a liquid). Next, the basic relation of dynamic gravimetry is derived to estimate the absolute mass of adsorbed material onto the surface of a submerged solid object. This relation encompasses, apart from the term related to the measured output signal of the balance, three correction terms which originate from the surface tension effects, buoyancy effect of the submerged object, and buoyancy effect due to the adsorbed material.The following sections address adsorption at the air-liquid interface as well as the molecular diffusion process (both being intermingled with concentration and density gradients in the system). Special attention is given to the errors connected with a series of relaxation processes in which the external menisci, the plate-beam system, and the surface tension are involved once their equilibrium conditions are disturbed. The time constants of these relaxation processes can not be exactly predicted. The paper concludes with an experimental illustration of dynamic gravimetry, with the adsorption of beta-lactoglobulin onto stainless steel plates. The validity of predictions based upon the physico-mathematical fundamentals is reconciled with the analytical and technical aspects and difficulties specific to dynamic gravimetry.

Angiogenesis is stimulated by a tumor-derived endothelial cell growth factor

A growth factor mitogenic for BALB/C 3T3 cells and capillary endothelial cells was isolated from a rat chondrosarcoma and purified to homogeneity. Purification was accomplished by a combination of BioRex 70 cation exchange chromatography and heparin affinity chromatography. The pure chondrosarcoma-derived growth factor (ChDGF) had a molecular weight of about 18,000. The angiogenesis activity of pure ChDGF was tested by measuring its ability to vascularize the chorioallantoic membrane (CAM) and yolk sac membrane of the developing chick. The ability of ChDGF to induce the growth of limbal vessels in the rat cornea was also measured. To quantitate the angiogenesis response, a unit system based on the growth factor activity of ChDGF for 3T3 cells was adopted. ChDGF was found to have a specific activity of about 5 units/ng when applied to 3T3 cells. About 300-600 units of ChDGF in the two types of developing chick membrane and 30-5 units of ChDGF in the rat cornea were found to stimulate noninflammatory angiogenesis.

Influence of time, temperature, moisture, ingredients, and processing conditions on starch gelatinization

Starch gelatinization phenomena is extremely important in many food systems. This review focuses on factors affecting gelatinization characteristics of starch. Important variables which must be considered in design of processes in which starch undergoes gelatinization are heat of gelatinization and temperature of gelatinization. Major interactions are reviewed for the effects of lipids, moisture content, nonionic constituents and electrolytes on these characteristics. Furthermore, treatment of starch-containing systems prior to heating into the gelatinization temperature range can have a significant effect on ultimate gelatinization characteristics.