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.

Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research

Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital

Medication administration errors and near misses are common including in mental health settings. Nurses should report all errors and near misses so that lessons can be learned and future mistakes avoided. We interviewed 50 nurses to find out if they would report an error that a colleague had made or if they would report a near-miss that they had. Less than half of nurses said they would report an error made by a colleague or a near-miss involving themselves. Nurses commonly said they would not report the errors or near misses because there was a good excuse for the error/near miss, because they lacked knowledge about whether it was an error/near miss or how to report it, because they feared the consequences of reporting it, or because reporting it was too much work. Mental health nurses mostly report similar reasons for not reporting errors and near misses as nurses working in general medical settings. We have not seen another study where nurses would not report an error or near miss because they thought there was a good excuse for it. Training programmes and policies should address all the reasons that prevent reporting of errors and near misses. Medication errors are a common and preventable cause of patient harm. Guidance for nurses indicates that all errors and near misses should be immediately reported in order to facilitate the development of a learning culture. However, medication errors and near misses have been under-researched in mental health settings. This study explored the reasons given by psychiatric nurses for not reporting a medication error made by a colleague, and the perceived barriers to near-miss reporting. We presented 50 nurses with clinical vignettes about error and near-miss reporting and interviewed them about their likely actions and about their views and perceptions. Less than half of participants would report an error made by a colleague (48%) or a near-miss involving themselves (40%). Thematic analysis revealed common themes for both not reporting an error or a near-miss were knowledge, fear, burden of work, and excusing the error. The first three themes are similar to results obtained from research in general medical settings, but the fourth appears to be novel. Many mental health nurses are not yet fully convinced of the need to report all errors and near misses, and that improvements could be made by increasing knowledge while reducing fear, burden of work, and excusing of errors.

Training support staff to modify fluids to appropriate safe consistencies for adults with intellectual disabilities and dysphagia: an efficacy study

BACKGROUND

Modifying the consistency of food and drink is a strategy commonly used in the management of dysphagia for people with intellectual disabilities (ID). People with ID often depend on others for the preparation of food and drink and therefore depend on those caregivers achieving the correct consistency to keep them safe and avoid discomfort during mealtimes. Clinical experience and prior research have demonstrated that although training can improve modification, carers often find modification difficult and potentially stressful and recommend additional support for carers. Fluid consistency is often modified through the addition of powdered thickener. This study investigates the efficacy of typical training and use of consistency guides, the Thickness Indicator Model (TIM) tubes, in helping carers to modify fluids accurately.

METHOD

A 3 × 3 pre-post experimental design with a control group was employed to compare the observed accuracy of modification across three groups and at three time points (pre-intervention baseline, immediately post-training intervention and 3-10 months post-training). Sixty-two paid carers who supported people with ID were recruited to participate in the study and each was randomly allocated to one of the three groups: a control group given written guidance only, a group who received typical training and written guidance and a group who received training, written guidance and the TIM tubes.

RESULTS & CONCLUSIONS

Typical training resulted in significantly greater carer accuracy in modifying fluid consistencies when compared with written guidance alone. Use of the TIM tubes also significantly improved accuracy in the modification of drinks compared with the group who modified with the aid of written guidance alone. At 3-10-month follow-up only the group who received typical training alongside the TIM tubes were significantly more accurate than the Written Guidance group. Further research is warranted to ascertain the effectiveness of the training and the utility of the TIM tubes in improving accuracy over a longer time scale and in individuals' usual living environments.

Health professionals', expert patients' and dieters' beliefs and attitudes about obesity

BACKGROUND

Research has suggested that patients and treatment providers hold different beliefs and models of obesity. This could impact upon the consistency and quality of interventions for weight management. The present study investigated the attitudes and beliefs of health professionals, commercial weight management advisors (expert patients) and overweight and obese dieters, towards obesity.

METHODS

Data were collected using a self-administered questionnaire from 287 health professionals, 85 expert patients and 116 dieters. Respondents gave their views on obesity causation and consequences, and the most efficacious means to manage obesity. Demographic data and self-reported height and weight were also collected. Factor analysis, analysis of variance and t-tests were used to analyse the data.

RESULTS

Health professionals, expert patients and dieters held similar models of obesity, identifying the same causes (lifestyle causes), consequences (medical consequences) and treatments (current recommended options) of obesity/overweight.

CONCLUSIONS

The findings of the present study indicate a broader similarity between beliefs and attitudes of those involved in obesity treatment and those that they aim to treat than was previously assumed. The concordance of beliefs between patients and treatment providers is an encouraging finding and may have important implications for public health strategies in this area.

An initial evaluation of a family-based approach to weight management in adolescents attending a community weight management group

BACKGROUND

Family-based approaches are recommended for the prevention and management of childhood obesity. Given the large numbers of obese children, scalable practical solutions are required. The present study evaluated a family-based national programme that aimed to empower adolescents to adopt healthier lifestyles.

METHODS

Group facilitators supporting more than six young members (11-15 years) participated in the study. A questionnaire was designed to determine the characteristics of the adult attending with the adolescent, any health professional recommendations given and the young member's integration within traditional adult weight management groups. Data on measured height and weight [and calculated body mass index (BMI)], sex and attendance were collated from member's records.

RESULTS

Questionnaires were completed by 22 facilitators (15% response rate), representing data for 128 young members with complete weight data available for 106. All members had a joining BMI > 91st centile, with 68% >98th centile. The mean (SD) number of weeks attended was 12.5 (8.1), with 19% (20) having attended for more than 20 weeks with 62% still attending. A mean (SD) BMI Z-score change of 2.49 (0.72) to 2.27 (0.74) was achieved (P < 0.001). The relationship of the adult supporter to the young member was varied, with 62% either already members or joining alongside their daughter/son. Limited guidance was provided by health professionals before or during attendance. Facilitators were comfortable about the age mix within groups.

CONCLUSIONS

The community weight management organisation studied takes a family-based approach and successfully supports young members to manage their weight.

Weight, body mass index and behaviour change in a commercially run lifestyle programme for young people

BACKGROUND

  There are few practical, scalable, community-based solutions that provide ongoing support to combat the recent rapid rise in obesity in young people. A commercial weight management organisation (CWMO) has developed a tailored version of its programme for young people. The present study assessed the programme's impact on self-reported body weight, body mass index (BMI; kg m(-2) ) and health-related behaviour changes in participating young people.

METHODS

  Seventy-nine current young members completed a web-based questionnaire on age, height, weight and self-reported eating and activity behaviours for when they joined the programme and at the time of survey. Inclusion criteria were age 11-15 years old and membership for at least 1 month. Subjects completed the questionnaire online via the CWMO website. This was a retrospective observational study without a control group. All data were self-reported.

RESULTS

  Mean (SD) age was 13.4 (1.4) years and start weight was 78.5 (16.7) kg; 67% were >99th centile for BMI. Mean (SD) attendance was 23 (19) weeks; weight change was -5.0 (4.5) kg; BMI change was -2.5 (2.0) kg m(-2) ; and BMI Z-score change was -0.5 (0.4) (all P < 0.001). Height increased by 0.01 (0.03) m (P < 0.01); however, height Z-score remained unchanged. Regression analysis showed that BMI Z-score change was related to increased fruit and vegetable intake (P = 0.012), as well as a decrease in avoidance of moderate and intense activity (both P < 0.003).

CONCLUSIONS

  This programme for overweight and obese young people helped implement behaviour and lifestyle changes that were associated with significant reductions in self-reported weight and BMI Z-score, without compromising growth in height.

Problems in identifying predictors and correlates of weight loss and maintenance: implications for weight control therapies based on behaviour change

Weight management is a dynamic process, with a pre-treatment phase, a treatment (including process) phase and post-treatment maintenance, and where relapse is possible during both the treatment and maintenance. Variability in the statistical power of the studies concerned, heterogeneity in the definitions, the complexity of obesity and treatment success, the constructs and measures used to predict weight loss and maintenance, and an appreciation of who and how many people achieve it, make prediction difficult. In models of weight loss or maintenance: (i) predictors explain up to 20-30% of the variance; (ii) many predictors are the sum of several small constituent variables, each accounting for a smaller proportion of the variance; (iii) correlational or predictive relationships differ across study populations; (iv) inter-individual variability in predictors and correlates of outcomes is high and (v) most of the variance remains unexplained. Greater standardization of predictive constructs and outcome measures, in more clearly defined study populations, tracked longitudinally, is needed to better predict who sustains weight loss. Treatments need to develop a more individualized approach that is sensitive to patients' needs and individual differences, which requires measuring and predicting patterns of intra-individual behaviour variations associated weight loss and its maintenance. This information will help people shape behaviour change solutions to their own lifestyle needs.

Covert administration of medication to older adults: a review of the literature and published studies

The aim of the study was to review published studies of covert medicines administration in older people, as well as carrying out a broad review of the subject. A review of MEDLINE, EMBASE, PsycINFO, BNI and CINAHL was conducted in order to identify studies providing quantitative or qualitative data on covert administration in older adults. National guidance on covert medication and the ethics and legality of the practice were also reviewed. Data were extracted from eight studies and one inspection report. In addition, one qualitative study was identified. Nine studies included a questionnaire or interview with staff and only one involved non-professional carers. Seven studies were from the UK. Disguising medication in food or drink was reported in 43-71% of nursing homes. In total, 1.5-17% of institutional patients were receiving medication covertly. Despite legislation, incomplete documentation was common and nursing staff alone often made the decision to administer medication covertly. Covert administration appears to be common in older adults with dementia but despite legislation it often takes place without documentation and consultation of all relevant parties. Staff education and training and local audit are needed to improve standards and safeguard vulnerable patients in institutions.

Off-label psychotropic prescribing for young persons in medium security

Psychotropic drug prescribing for children and adolescents is frequently off-label and has increased over time and can be controversial. Psychotropic prescribing in two large UK medium secure units for young people has been studied. A total of 89 patients were included, 64% being aged less than 18 years. A total of 137 of 202 (67.8%) of prescriptions were off-label. The most common reasons for a prescription being off-label were the indication (N = 103) and the patient's age (N = 41). The main classes of drugs involved were antipsychotics (N = 59), antiepileptics as mood stabilisers (N = 22), anticholinergics and hyoscine (N = 15) and antidepressants (N = 11). Aggression (N = 48) and post-traumatic stress disorder (N = 30) were the most common off-label indications. Some antidepressant prescriptions were contrary to advice of the Committee on Safety of Medicines (CSM). Meta-analyses or randomised controlled trials supported 27% of off-label prescriptions, with lesser quality studies supporting a further 29.2% and expert opinion 38.7%, whereas for 5.1% no evidence could be found. Prescribers tended to over-estimate the level of evidence from clinical trials or extrapolated from findings in adults. They often quoted their own experience rather than expert sources to justify their prescribing practice. It is important that prescribers are fully aware of the quality of experimental data and the risk-benefit ratio when prescribing off-label for young persons. If the evidence base is limited, it is particularly important to provide information about the risks and benefits of the treatment to the patient/relatives. A second opinion may be helpful. Both target symptoms and side effects should be monitored and regularly reviewed.

Low mannose-binding lectin complement activation function is associated with predisposition to Legionnaires' disease

Innate immune system deficiency may predispose to severe infections such as Legionnaires' disease. We have investigated the role of mannose-binding lectin (MBL) deficiency in the Melbourne Aquarium Legionnaires' disease outbreak. Serum samples from patients and controls that were exposed but shown to be uninfected from the Melbourne Aquarium Legionnaires' disease outbreak were tested for MBL function (C4 deposition) and level (mannan-binding). MBL function was lower in Legionnaires' disease cases than in age- and sex-matched uninfected, exposed controls. The frequency of MBL deficiency with C4 deposition < 0.2 U/microl was significantly higher in Legionnaires' disease cases than in controls. This also applied to Legionnaires' disease cases requiring hospital care. There was no difference in MBL mannan-binding levels between Legionnaires' disease patients and controls. There was no significant interval change in MBL function or level after a mean of 46 days. MBL complement activation functional deficiency appears to predispose to Legionnaires' disease.

Smoking in a forensic psychiatric service: a survey of inpatients' views

Smoking in a forensic psychiatric service: a survey of inpatients' views Very little is known concerning the views and beliefs of psychiatric inpatients about smoking in hospital. We conducted a survey of inpatients from the forensic wards of a large independent psychiatric hospital using a structured interview to collect data about their views on smoking. Of 102 patients eligible to participate, 45 (44.1%) agreed to do so. Most participants (34, 75.6%) were current smokers. Most smokers thought it was just too difficult to give up smoking (25, 73.5%). They cited seeing staff and other patients smoking, as well as the smoky atmosphere on the ward, as barriers to quitting. The majority of participants (35, 77.8%) thought that staff should be allowed to smoke with patients. Smokers held more liberal views about smoking than non-smokers. A smaller proportion of non-smokers than smokers were happy with the hospital smoking policy, as reflected in the ward rules about smoking. The results of this survey suggest that a change in attitude and culture towards smoking may be needed in psychiatric units. Smokers should be regularly offered help and encouragement to quit. Psychiatric care staff should carefully consider whether their own smoking behaviour undermines their patients' attempts to stop smoking. More attention should be given to the views and needs of non-smokers.

A survey of off-label prescribing for inpatients with mild intellectual disability and mental illness

BACKGROUND

The term 'off-label prescribing' refers to the use of a drug outside the terms of its Marketing Authorisation, including prescribing for an unlicensed indication. There have been few reports about off-label prescribing in psychiatry. The aims of the study were to determine the frequency of off-label prescribing of psychotropics for inpatients with mild intellectual disability (ID) and mental illness resident in a large psychiatric hospital, the nature of the off-label clinical indications and details about patient consent and case note documentation of the off-label usage.

METHODS

Cross-sectional survey of inpatients of the ID division of a charitable hospital was carried out. Interviews with consultant psychiatrists about off-label use of psychotropics were also made.

RESULTS

Of the 56 patients studied, 38 (67.9%) were receiving one or more psychotropic drugs and 26 (46.4%) were receiving at least one off-label psychotropic. The most frequently cited off-label indications were: reduction of aggression, arousal and behavioural disturbance (14 cases) and mood stabilization of affective disturbance (13). The principle psychotropics involved were atypical antipsychotics (17 cases) and mood stabilizers (13). Although in most instances the psychiatrist was aware the drug was being used off-label and had consulted other professionals, in only two (6%) instances had the patient been informed of the off-label usage, largely because the psychiatrist felt they lacked the capacity to understand the off-label concept. In most cases the off-label usage had not been documented in the case notes.

CONCLUSIONS

Off-label prescribing is common in patients with comorbid ID and mental disorder. When prescribing off-label, psychiatrists need to consider the evidence that the drug is likely to be effective for the unlicensed indication and any risks involved. Where there is limited evidence of benefit a trial of the drug, with clinical monitoring may be indicated. Patients should be fully informed about their medication. However, many patients with ID cannot understand the off-label concept. In some circumstances psychiatrists may find it helpful to consult other professionals before prescribing off-label. Good case note documentation of the process is important and supports the prescriber.

Risk factors for coronary heart disease among inpatients who have mild intellectual disability and mental illness

BACKGROUND

Coronary heart disease (CHD) is a major cause of morbidity and mortality in the UK. The aim of this study was to screen inpatients with mild or borderline intellectual disability, many of whom also have mental illness, for risk factors for CHD.

METHODS

Cross sectional survey. Participants were interviewed, measured and had blood samples taken.

RESULTS

Of the 53 participants, 20 (37.7%) were overweight and 18 (34.0%) obese. The mean body mass index (BMI) of those participants prescribed regular antipsychotics was higher than those who were not. Nine (20.9%) had waist circumference measurements placing them at increased risk of CHD and 21 (48.8%) were at substantially increased risk. Twenty-eight (52.8%) were current smokers. Of the 49 participants who had their blood pressure measured, 3 (6.1%) had readings above the reference range. Of the 19 participants who had random blood tests, one (5.3%) had an elevated cholesterol level.

CONCLUSIONS

In this population there was a high prevalence of two risk factors for CHD (obesity and smoking), requiring ongoing monitoring and long-term measures to reduce risk.

Predicting basal metabolic rate in the obese is difficult

OBJECTIVE

To reassess the validity of the Schofield equations for predicting basal metabolic rate (BMR) in the obese.

DATA

The data collection compiled from many studies by Schofield in 1985.

METHODS

Nonparametric curve fitting and comparison of groups.

RESULTS

BMR increases more slowly at heavier weights in men (above about 75 kg) and women (above about 65 kg), and to ignore this is to predict overestimates of BMR. Data obtained from studies of different populations show substantial differences, which are influential when data are combined.

CONCLUSIONS

The Schofield equations are unsuitable for obese populations. Given that current Western populations exhibit prevalences of obesity many times greater than those in the Schofield database, this indicates the need for further study of suitable predictors for these individuals.

Genetic mapping with SNP markers in Drosophila

Map-based positional cloning of Drosophila melanogaster genes is hampered by both the time-consuming, error-prone nature of traditional methods for genetic mapping and the difficulties in aligning the genetic and cytological maps with the genome sequence. The identification of sequence polymorphisms in the Drosophila genome will make it possible to map mutations directly to the genome sequence with high accuracy and resolution. Here we report the identification of 7,223 single-nucleotide polymorphisms (SNPs) and 1,392 insertions/deletions (InDels) in common laboratory strains of Drosophila. These sequence polymorphisms define a map of 787 autosomal marker loci with a resolution of 114 kb. We have established PCR product-length polymorphism (PLP) or restriction fragment-length polymorphism (RFLP) assays for 215 of these markers. We demonstrate the use of this map by delimiting two mutations to intervals of 169 kb and 307 kb, respectively. Using a local high-density SNP map, we also mapped a third mutation to a resolution of approximately 2 kb, sufficient to localize the mutation within a single gene. These methods should accelerate the rate of positional cloning in Drosophila.

Methodological considerations when conducting direct observation in an outdoor environment: our experience in local parks

OBJECTIVE

This paper discusses some of the inherent methodological limitations of gathering data via direct observation using local parks as a case study.

METHODS

Direct observation was carried out in five parks on seven non-consecutive days in 1998 and on matched days in 1999. Information recorded for each person included the time of park entry and exit, gender, age group, and activity/ies undertaken while in the park. METHODOLOGICAL CONSIDERATIONS: The location of the observation point, observer reliability, recording and accuracy of data, and specific issues related to outdoor observation areas should all be considered when designing a study incorporating direct observation as a data collection method.

CONCLUSIONS

Direct observation can provide valuable information. However, pilot testing is essential for minimising potential problems associated with this method and optimising data quality.

IMPLICATIONS

The issues discussed in this paper provide a useful guide for other researchers undertaking direct observation in outdoor environments.

Energy density of foods: effects on energy intake

This article examines the importance of dietary energy density (ED) as a major factor that may influence human appetite and energy intake (EI). The article examines whether the effects of diet composition on appetite and EI can be explained in terms of ED. There is clear evidence that dietary macronutrients exert differential effects on energy intake (EI), both in the laboratory and in real life. Under normal conditions where fat contributes disproportionately to ED, protein, carbohydrate, and fat exert hierarchical effects on satiety in the order protein >carbohydrate > fat. Alcohol appears to stimulate EI. In human appetite studies the main effect of controlling ED is to diminish the impact of differences in the satiating effects of fat and carbohydrate. ED exerts profound effects in constraining EI in short-to-medium term studies. Subjects behave differently in longer term interventions. In short-to-medium term laboratory studies, increases in ED are more effective at increasing EI than at decreasing food intake. In longer term and cross-sectional studies conducted in naturalistic environments, increased ED appears more effective at decreasing food intake and less effective at elevating EI. The available evidence suggests that we should be evolving more complex, multifactor models to account for the observations that both macronutrients and ED affect EI rather than substituting one simplistic model with another.

Graded expression of EphA3 in the retina and ephrin-A2 in the superior colliculus during initial development of coarse topography in the wallaby retinocollicular projection

We describe the expression of EphA3 and EphA7 receptors and ephrin-A2 ligand in the retina and the superior colliculus during the development of the retinocollicular projection in the marsupial wallaby (Macropus eugenii), using immunoblotting and immunohistochemistry. EphA3 in the retina was in a striking, low central to high peripheral gradient, superimposed on which was a high temporal to low nasal level of expression. This distribution was evident from postnatal day 30, when axons are growing into the colliculus and forming a coarsely organized topographic projection, to postnatal day 65, when axons have arborized in their correct retinotopic positions. EphA7 showed a shallow centroperipheral gradient with no nasotemporal differences in expression. In the superior colliculus no rostrocaudal differences in distribution were detected for either of these receptors. Ephrin-A2 was distributed in a gradient increasing from the rostral to the caudal pole in the superficial layers of the superior colliculus only up to postnatal day 30. Ephrin-A2 was evenly distributed in the retina throughout development of the projection. Expression of EphA3 in the retina increased, while the expression of ephrin-A2 in the colliculus was downregulated over time. The graded expression of EphA3 and ephrin-A2 early in the development of the projection suggests that they play a role in establishment of coarse topography of retinal axons along the rostrocaudal axis of the superior colliculus. However, the gradients were not complementary, meaning that EphA3 alone cannot mediate the repulsive interactions with ephrin-A2 that have been postulated to underlie formation of the topographic map.

Gender in development: a long haul -- but we're getting there!

While women's movements in Latin America and elsewhere have succeeded in putting many issues that are relevant to women and to gender relations onto the political agenda, and although most international aid agencies have made efforts to incorporate gender analysis into their work, this progress has been neither comprehensive nor unproblematic. This article focuses on ways in which the development cooperation agenda, and the priorities and working methods of development agencies and nongovernmental organizations, have served to distort the vision and practice of the women's organizations whose work they seek to support.

Evaluation of linked cancer registry and hospital records of breast cancer

BACKGROUND

Information on the treatment of women with breast cancer in Australia is generally available only from special surveys. Analysis of routinely collected datasets may be more timely and cost effective, if the data are sufficiently accurate and complete.

OBJECTIVE

To evaluate the accuracy and completeness of data on treatment in linked records of breast cancer from two routinely collected datasets.

METHODS

The NSW Department of Health linked NSW Central Cancer Registry (CCR) records for 2,636 women diagnosed with breast cancer in NSW in 1992 to all hospital admission records in the NSW In-patient Statistics Collection (ISC) from January 1991 to June 1994. We queried the original paper records of subsets of women to identify missing or miscoded information and cases not notified to the CCR. We also compared the treatment data with data collected independently from the medical records of 19% of the women.

RESULTS

ISC records linked to 89% of the CCR records. The CCR had identified 94.9% of women with breast cancer treated as hospital in-patients and 83% of these women had surgical treatment recorded in the ISC. The linked dataset under-estimated the percentage of women having breast-conserving therapy (-4%) and slightly over-estimated the percentage having mastectomy (+1%). We estimated that 42% of women treated surgically for breast cancer had actually had breast-conserving surgery, compared with 39% in the original dataset. There was no evident bias by age or by urban or rural residence in the under-recording of breast conservation. There was 94% agreement on the type of surgery between the linked dataset and the independent dataset.

The transposable element Tan1 of Aspergillus niger var. awamori, a new member of the Fot1 family

Aspergillus niger var. awamori has transposable elements that we refer to as Vader and Tan1 (transposon A. niger). Vader was identified by screening unstable nitrate reductase (niaD) mutants for insertions. Four of the isolated niaD mutants were shown to contain a small insertion element. This 437 bp insertion element, Vader, is flanked by 44 bp inverted repeats (IR) and is present in approximately 15 copies in the genomes of two A. niger strains examined. A synthetic 44 bp oligomer of the inverted repeat of Vader has now been used to clone, via the polymerase chain reaction, a 2.3 kb Tan1 element. The Tan1 element has also been isolated from a partial genomic library. Tan1 is present as a single copy in A. niger var. awamori. The Tan1 element has a unique organization: IR-ORF-IR-IR-Vader-IR. The single open reading frame (ORF) (1668 bp) encodes a putative transposase homologous to Fusarium oxysporum Fot1 and Magnaporthe grisea Pot2. Immediately 3' to the second inverted repeat, which bounds the transposase, is a copy of the AT-rich Vader element. We hypothesize that at some stage the independent Vader element, although inactive by itself, arose from Tan1, resulting in current strains with only one copy of Tan1 providing transposase activity and numerous mobile copies of Vader dispersed in the genome.

Identification and cloning of a mobile transposon from Aspergillus niger var. awamori

Aspergillus niger var. awamori contains multiple copies of a transposable element, Vader. This element was detected as a 437-bp insertion in four independently isolated spontaneous mutants of the niaD (nitrate reductase) gene. The Vader element is present in approximately 15 copies in both A. niger var. awamori and A. niger. A single copy of Vader was detected from only one of the two laboratory strains of A. nidulans which were also examined. Insertion of the Vader element into the niaD gene of A. niger var. awamori caused a 2-bp duplication (TA) of the target sequence. The Vader element is flanked by a 44-bp inverted repeat. The genetic stabilities of the inserted Vader elements at niaD were examined by studying reversion frequencies resulting in colonies able to grow on nitrate as a sole nitrogen source. Mutants niaD392 and niaD436 reverted at a frequency of 9x10(-3) and 4x10(-2), respectively. Two of the mutants, niaD587 and niaD410, reverted at a lower frequency of 6x10(-4).

The Edinburgh Postnatal Depression Scale: validation for an Australian sample

One hundred and three post-partum women completed the Edinburgh Postnatal Depression Scale (EPDS) and were interviewed using the Diagnostic Interview Schedule. A cut-off score of 12.5 on the Edinburgh Postnatal Depression Scale identified all nine women who reached criteria for major depression. At this threshold the sensitivity (the percentage of true "cases" identified) of the EPDS was 100%, its specificity (the percentage of true "non-cases" identified as such) 95.7% and its positive predictive value (the percentage of all those tested as positive who were correctly identified as such) 69.2%. Although this study supported the validity of the EPDS, a replication of this study on a larger sample is suggested.

Studies of Muc-1 mucin expression and polarity in the mouse mammary gland demonstrate developmental regulation of Muc-1 glycosylation and establish the hormonal basis for mRNA expression

Muc-1 is a major mucin glycoprotein expressed on the surface of mammary epithelial cells. It has attracted considerable attention as it is expressed in an aberrant form on many breast tumor cells. Here we describe studies using a recently obtained cDNA probe of Muc-1 expression during lactogenic development in the mouse. Northern blot analysis demonstrated that Muc-1 is expressed at all stages of lactogenic development but its levels are increased very significantly during mid-pregnancy and into lactation. The basis of this was examined using CID-9 mammary epithelial cell cultures. It was found that in the presence of insulin Muc-1 mRNA levels were increased by both hydrocortisone and prolactin, with the combination of the three hormones supporting maximum expression. Muc-1 mRNA levels were also modulated by culturing cells on a basement-membrane-like extracellular matrix that promoted mRNA levels 5- to 10-fold above levels in cells cultured on plastic tissue culture dishes. Immunocytochemical studies using monoclonal antibodies to carbohydrate epitopes on Muc-1 demonstrated that while Muc-1 was found at all developmental stages, it became increasingly sialylated during the course of pregnancy and into lactation. Additionally, we found that while Muc-1 is tightly polarized to the apical surface of the epithelium of lactating and pregnant mice it exhibited a less-polarized distribution on a small proportion of ductal cells in virgin mice. We conclude that the expression of Muc-1 is regulated at several different levels and by a number of different factors. We speculate that this may reflect different functional roles for Muc-1 at different stages of mammary development.

Adhesive multiplicity in the interaction of embryonic fibroblasts and myoblasts with extracellular matrices

Neff et al. (1982, J. Cell Biol., 95:654-666) have described a monoclonal antibody, CSAT, directed against a cell surface antigen that participates in the adhesion of skeletal muscle to extracellular matrices. We used the same antibody to compare and parse the determinants of adhesion and morphology on myogenic and fibrogenic cells. We report here that the antigen is present on skeletal and cardiac muscle and on tendon, skeletal, dermal, and cardiac fibroblasts; however, its contribution to their morphology and adhesion is different. The antibody produces large alterations in the morphology and adhesion of skeletal myoblasts and tendon fibroblasts; in contrast, its effects on the cardiac fibroblasts are not readily detected. The effects of CSAT on the other cell types, i.e., dermal and skeletal fibroblasts, cardiac muscle, 5-bromodeoxyuridine-treated skeletal muscle, lie between these extremes. The effects of CSAT on the skeletal myoblasts depends on the calcium concentration in the growth medium and on the culture age. We interpret these differential responses to CSAT as revealing differences in the adhesion of the various cells to extracellular matrices. This interpretation is supported by parallel studies using quantitative assays of cell-matrix adhesion. The likely origin of these adhesive differences is the progressive display of different kinds of adhesion-related molecules and their organizational complexes on increasingly adhesive cells. The antigen to which CSAT is directed is present on all of the above cells and thus appears to be a lowest common denominator of their adhesion to extracellular matrices.

The effect of cardiac denervation and beta-blockade on control of cardiac output in exercising dogs

Normal and cardiac denervated dogs, with an electromagnetic aortic flowprobe implanted at least 14 days before the experiments, ran at different speeds on a 25% graded treadmill. The experiments were carried out before and after blockade of betareceptors in the heart by PO administration of 125 mg X kg-1 practolol per day. Changes in stroke volume, heart rate, and cardiac output were measured. After beta-adrenergic blockade, only two of the seven dogs with denervated hearts were prepared to run at a limited number of speeds. Time constants of the cardiac output changes at the onset of exercise were significantly different (P less than 0.001) for the normal (11.5 +/- 0.7 s, mean +/- SEM) and the denervated dogs (29.5 +/- 1.1 s), but in normal dogs did not change with practolol (11.8 +/- 0.8 s). The steady state relationship between cardiac output (CO) and work per unit time performed on the treadmill (P) was for normal dogs: CO = 156 + 1.55P, for normal dogs after practolol treatment: CO = 156 + 0.43P (slope significantly different, P less than 0.05), and for dogs with denervated hearts: CO = 121 + 2.06P (not significantly different from normal dogs). It was concluded that changes in the venous or arterial system alone are not sufficient to increase cardiac output appreciably during exercise. The magnitude of the cardiac output increase depends more on the presence of intact beta-receptors than on the presence of intact cardiac nerves.(ABSTRACT TRUNCATED AT 250 WORDS)

Species Suitability on a Lowland Site Altered by Drainage

Surface drainage created adequate conditions for survival and growth of loblolly pine (Pinus taeda L.) on most sites within a wet lowland area. Successful pine establishment occurred on soils having loamy or sandy surface horizons and where original forest cover had been pine-hardwood or hardwood. On a lesser but significant number of sites, however, loblolly pine had unsatisfactory survival. Such problems were common where clay content of surface soil was high and the water table remained near the surface after ditch installation. In most cases, these conditions occurred on sites formerly occupied by cypress-hardwood timber. Planted sweetgum (Liquid ambar styraciflua L.) and baldcypress (Taxodium distichum (L.) Rich.) had better survival than loblolly pine on these sites. Guidelines for delineating such problem sites are given and management alternatives discussed.

The role of the cardiac nerves in regulation of sodium excretion in conscious dogs

Conscious, chronically instrumented dogs, maintained on a high sodium intake, were used to investigate whether surgical cardiac denervation impairs the natriuresis associated with left atrial pressure increase produced in three ways: during an increase in left atrial pressure by means of a reversible mitral stenosis (protocol 1); after an i.v. saline load (1.0 ml 0.9% saline min-1 . kg-1 over 60 min) (protocol 2); after an oral saline load (14.5 mmol Na . kg-1 given with the food as isotonic solution) (protocol 3). During a reversible mitral stenosis, in intact dogs, urine volume and sodium excretion increased markedly (from 34--145 microliters . min-1 . kg-1 and from 3--12 mumol . min-1 . kg-1); mean arterial pressure increased by an average of 2 kPa (15 mm Hg) and heart rate by 53 b/min; plasma renin activity fell from 0.37--0.21 ng AI . ml-1 . h-1 . Cardiac denervation eliminated these effects of left atrial distension except for a small increase in heart rate (12 b/min). This indicates that the natriuresis and diuresis during left atrial distension resulted from stimulation of receptors located in the left atrium. In contrast, during protocol 2 and 3, the same amounts of sodium and water were excreted in the cardiac denervated dogs as compared to the intact dogs. A comparable decrease in plasma renin activity also was observed. -- Apparently the presence of the cardiac nerves is not a prerequisite for maintenance of sodium and water homeostasis.