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.

Lessons learned from a pneumocystis pneumonia outbreak at a Scottish renal transplant centre

BACKGROUND

Pneumocystis pneumonia (PCP) is an opportunistic infection occurring in renal transplant patients. Over a 14-month period an increase in PCP cases was identified among our renal transplant cohort.

AIM

The outbreak population was studied to identify potential risk factors for the development of PCP.

METHODS

A retrospective analysis of hospital records was carried out, with each case being matched with two case-linked controls. Information was collected on patient demographics, laboratory tests, and hospital visits pre and post development of infection.

FINDINGS

No patients were receiving PCP prophylaxis at the time of infection and mean time from transplantation to developing PCP was 4.7 years (range: 0.51-14.5). The PCP group had a significantly lower mean estimated glomerular filtration rate than the control group (29.3 mL/min/1.73 m² vs 70 mL/min^-1 (P = 0.0007)). Three patients were treated for active cytomegalovirus (CMV) infection prior to PCP diagnosis and two had active CMV at the time of diagnosis compared to none in the control group (P = 0.001). Those who developed PCP were more likely to have shared a hospital visit with another patient who went on to develop PCP; 37% of clinic visits vs 19% (P = 0.014).

CONCLUSION

This study highlights the ongoing risk of opportunistic infection several years after transplantation and adds weight to potential person-to-person Pneumocystis jirovecii transmission. Risk factors have been identified which may highlight those most at risk, enabling targeted rather than blanket long-term PCP prophylaxis.

Weather and soil type affect incidence of fasciolosis in dairy cow herds

Fasciolosis caused by Fasciola hepatica is generally a subclinical infection of dairy cows and can result in marked economic losses on Irish dairy farms. This study investigated the exposure to F hepatica in 237 dairy cow herds, using an in-house antibody-detection ELISA applied to bulk tank milk (BTM) samples collected in the autumn of 2012. A total of 364 BTM samples were collected from 237 different herds, with 127 farmers submitting BTM samples in two consecutive months. Analysis of the BTM samples indicated that 67 per cent (n= 159) of the dairy herds had been exposed to F hepatica. Rainfall, temperature and soil types were significantly different between the exposed and non-exposed herds (P<0.05), highlighting the role of these variables to the exposure to F hepatica. Among the 127 herds that provided two monthly milk samples, 83 herds were exposed to F hepatica and 82 increased their F hepatica antibody levels at the later sampling time (P<0.01).The findings of this study confirm the high prevalence of F hepatica antibodies in Irish dairy herds and show the rise in antibody levels during autumn. This study is the first step towards assessing the spatiotemporal pattern of fasciolosis in dairy herds in Ireland.

Paramagnetic particles and mixing in micro-scale flows

Mixing in microscale flows with rotating chains of paramagnetic particles can be enhanced by adjusting the ratio of viscous to magnetic forces so that chains dynamically break and reform. Lattice Boltzmann (LB) simulations were used to calculate the interaction between the fluid and suspended paramagnetic particles under the influence of a rotating magnetic field. Fluid velocities obtained from the LB simulations are used to solve the advection diffusion equation for massless tracer particles. At relatively high Mason numbers, small chains result in low edge velocities, and hence mixing is slower than at other Mason numbers. At low Mason numbers, long, stable chains form and produce little mixing toward the center of the chains. A peak in mixing rate is observed when chains break and reform. The uniformity of mixing is greater at higher Mason numbers because more small chains result in a larger number of small mixing areas.

Innexins get into the gap

Connexins were first identified in the 1970s as the molecular components of vertebrate gap junctions. Since then a large literature has accumulated on the cell and molecular biology of this multi-gene family culminating recently in the findings that connexin mutations are implicated in a variety of human diseases. Over two decades, the terms "connexin" and "gap junction" had become almost synonymous. In the last few years a second family of gap-junction genes, the innexins, has emerged. These have been shown to form intercellular channels in genetically tractable invertebrate organisms such as Drosophila melanogaster and Caenorhabditis elegans. The completed genomic sequences for the fly and worm allow identification of the full complement of innexin genes in these two organisms and provide valuable resources for genetic analyses of gap junction function.

Two Drosophila innexins are expressed in overlapping domains and cooperate to form gap-junction channels

Members of the innexin protein family are structural components of invertebrate gap junctions and are analogous to vertebrate connexins. Here we investigate two Drosophila innexin genes, Dm-inx2 and Dm-inx3 and show that they are expressed in overlapping domains throughout embryogenesis, most notably in epidermal cells bordering each segment. We also explore the gap-junction-forming capabilities of the encoded proteins. In paired Xenopus oocytes, the injection of Dm-inx2 mRNA results in the formation of voltage-sensitive channels in only approximately 40% of cell pairs. In contrast, Dm-Inx3 never forms channels. Crucially, when both mRNAs are coexpressed, functional channels are formed reliably, and the electrophysiological properties of these channels distinguish them from those formed by Dm-Inx2 alone. We relate these in vitro data to in vivo studies. Ectopic expression of Dm-inx2 in vivo has limited effects on the viability of Drosophila, and animals ectopically expressing Dm-inx3 are unaffected. However, ectopic expression of both transcripts together severely reduces viability, presumably because of the formation of inappropriate gap junctions. We conclude that Dm-Inx2 and Dm-Inx3, which are expressed in overlapping domains during embryogenesis, can form oligomeric gap-junction channels.

Psychosocial predictors of adherence to nutritional recommendations and growth outcomes in children with cystic fibrosis

This study aimed to elucidate the relationship between maternal psychosocial factors related to dietary adherence and growth outcomes in their children with cystic fibrosis (CF). Twenty-five children with CF and mild lung disease, aged 7-12 years, were weighed and measured and completed detailed food records. Mothers completed questionnaires that measured general nutritional knowledge, nutritional knowledge specific to CF, coping strategies, dieting behaviors, self-efficacy about the ability to provide the correct diet, and attitudes and beliefs about CF. Of the cohort, only 16% adhered to the dietary recommendations. Dietary adherence was positively correlated with weight. Maternal nutritional knowledge specific to CF significantly predicted children's dietary adherence score. There was a significant negative correlation between the child's weight and mothers who were dieting successfully. Other psychosocial factors assessed were not related to dietary adherence. Improving the mother's knowledge about nutritional needs in CF appears worthwhile and may have an impact on growth.

Physiological and psychosocial contributors to malnutrition in children with cystic fibrosis: review

Malnutrition was once thought to be an inevitable consequence of cystic fibrosis (CF). It is now considered preventable but still contributes considerable morbidity in children. Malnutrition is linked to poorer pulmonary function, reduced survival and quality of life. As the anticipated lifespan of children with CF continues to lengthen, the prevention of malnutrition attains greater importance. This review explores the complex organic and psychosocial factors implicated in the aetiology of malnutrition associated with CF.

Relation between dietary intake and nutritional status in cystic fibrosis

This study evaluated adherence to current dietary recommendations of children with cystic fibrosis and mild lung disease and their siblings by comparing energy intake. Fifty children (25 with cystic fibrosis) aged between 7 and 12 years completed the study. Energy intake was assessed by weighed dietary intake, resting energy expenditure was used to calculate recommended daily intakes. The children with cystic fibrosis had significant deficits in Z scores for both height and weight compared with their siblings, but there was no difference in percentage of ideal weight for height. The cystic fibrosis group had a significantly higher energy intake per kilogram body weight per day but there was no difference in the percentage of energy derived from fat, protein or carbohydrate. Energy intake (per kg/day) and fat intake (g/kg) were both significant predictors of weight for height in the cystic fibrosis group. Targets for dietary management in cystic fibrosis should perhaps be related to fat intake per kilogram body weight.

Current approaches to the nutritional management of cystic fibrosis in Australia

OBJECTIVE

The aim of this study was to determine current Australian practice for the nutritional management of cystic fibrosis (CF) and compare it to USA and UK guidelines.

METHODOLOGY

A structured questionnaire was completed by dietitians from 15 major CF centres. It was estimated that these centres manage or co-manage 84% of Australians with CF.

RESULTS

There was close agreement between UK and USA guidelines and Australian practice for dietary intervention strategies, nutritional monitoring and surveillance, and electrolyte replacement. Infant feeding practices were more closely aligned with the UK. There were some differences in the areas of pancreatic enzyme replacement therapy, vitamin requirements in CF and dietary management of CF-related diabetes.

CONCLUSIONS

Despite the lack of formal agreement, nutritional management practices of most Australian centres are closely aligned with current published international recommendations. However, there is need for consensus in the area of enzyme replacement therapy, management of CF-related diabetes and vitamin supplementation based on optimal clinical outcomes.

Drosophila Shaking-B protein forms gap junctions in paired Xenopus oocytes

In most multicellular organisms direct cell-cell communication is mediated by the intercellular channels of gap junctions. These channels allow the exchange of ions and molecules that are believed to be essential for cell signalling during development and in some differentiated tissues. Proteins called connexins, which are products of a multigene family, are the structural components of vertebrate gap junctions. Surprisingly, molecular homologues of the connexins have not been described in any invertebrate. A separate gene family, which includes the Drosophila genes shaking-B and l(1)ogre, and the Caenorhabditis elegans genes unc-7 and eat-5, encodes transmembrane proteins with a predicted structure similar to that of the connexins. shaking-B and eat-5 are required for the formation of functional gap junctions. To test directly whether Shaking-B is a channel protein, we expressed it in paired Xenopus oocytes. Here we show that Shaking-B localizes to the membrane, and that its presence induces the formation of functional intercellular channels. To our knowledge, this is the first structural component of an invertebrate gap junction to be characterized.

Elemental content of airway surface liquid from infants with cystic fibrosis

We tested the hypothesis that airway surface liquid (ASL) electrolyte composition is altered in infants with cystic fibrosis (CF) and that the presence of airway inflammation affects ASL composition. We measured the tracheal ASL sodium and chloride concentration and examined bronchoalveolar lavage (BAL) fluid cytology, interleukin-8 (IL-8) concentrations, and quantitative bacterial culture in 19 infants and young children with CF. Seven infants undergoing bronchoscopy for the evaluation of stridor served as non-CF controls. In addition, we measured nasal ASL sodium and chloride concentrations from 10 young adults with CF and from 10 control subjects. On the basis of the BAL findings, the infants with CF were divided into three groups: one with little evidence of pulmonary inflammation (CF-NI, n = 5); one with obvious pulmonary inflammation (CF-I, n = 7); and an intermediate group (CF-MI, n = 7). We found the ASL sodium was not different among any of the four groups (means mM +/- SE, 85 +/- 10 controls; 78 +/- 16 CF-NI; 83 +/- 9 CF-MI, 84 +/- 9 CF-I). In contrast the ASL chloride was lower in the CF-NI group when compared with control subjects (108 +/- 5 control subjects; 77 +/- 7 CF-NI, p < 0.01). In the CF-I and CF-MI groups, the ASL chloride concentrations were of intermediate values (CF-I 95 +/- 10 mM; CF-MI 96 +/- 9 mM) and not significantly different from controls. Results from the nasal ASL analysis showed no significant differences in sodium and chloride concentrations in the CF group compared with control subjects. These results suggest that the primary abnormality of ASL composition is a reduction in chloride concentration. ASL composition appears to be affected by the presence of airway inflammation.

Surfactant composition in infants and young children with cystic fibrosis

We tested the hypothesis that the composition of bronchial surfactant is normal in infants with cystic fibrosis (CF) in the absence of active lung disease but that it is altered by lower respiratory tract infection and inflammation. We examined the total phospholipid (PL), disaturated phospholipid (DSP), surfactant protein-A (SP-A), surfactant protein B (SP-B), and surface activity in bronchoalveolar lavage fluid from 27 subjects with CF whose mean age was 22.7 (SD 14.5) mo. Six infants with stridor served as non-CF controls. Twelve of the subjects with CF (CF-I group) had evidence of active pulmonary infection or inflammation which was absent in the remaining 15 subjects (CF-NI group). We found no differences in the surfactant composition or activity between controls and the CF-NI group. In contrast, the DSP/PL ratio was lower in the CF-I subjects than in both the CF-NI subjects (p = 0.05) and controls (p < 0.01) suggesting a disturbance of surfactant function. SP-A concentrations were higher in the CF-I group compared to the other two groups (p < 0.05). These results suggest that the bronchial surfactant of infants with CF is altered following lower airway infection and inflammation and is not a primary abnormality associated with this disorder.

Pulmonary oxidative stress response in young children with cystic fibrosis

BACKGROUND

It has been suggested that oxidative stress contributes to lung injury in cystic fibrosis. There is, however, no direct evidence of increased pulmonary oxidative stress in cystic fibrosis nor of the effects of inflammation on the major pulmonary antioxidant, glutathione. A study was undertaken to measure these parameters in infants and young children in the presence or absence of pulmonary inflammation.

METHODS

Thirty two infants and young children with cystic fibrosis of mean (SD) age 21.4 (15.3) months (range 2-54) and seven non-cystic fibrosis control subjects of mean (SD) age 21.0 (21.2) months (range 2-54) were studied using bronchoalveolar lavage (BAL). On the basis of the BAL findings the cystic fibrosis group was divided into those with (CF-I) and those without pulmonary inflammation (CF-NI). Levels of lipid hydroperoxide, total glutathione, and gamma-glutamyl transpeptidase (gamma-GT) were then measured in the BAL fluid.

RESULTS

The concentrations of lipid hydroperoxide and gamma-GT in the epithelial lining fluid were significantly increased in the CF-I group compared with the control and CF-NI groups, each of which had similar values for these parameters (ratio of geometric means for CF-I group versus control for lipid hydroperoxide 5.4 (95% confidence interval (CI) 1.8 to 15.8) and for gamma-GT 5.2 (95% CI 1.4 to 19.4)). The glutathione concentration tended to be lower in the CF-I subjects but the difference did not reach statistical significance.

CONCLUSIONS

These results demonstrate that the airways in patients with cystic fibrosis are exposed to increased oxidative stress which appears to be a consequence of pulmonary inflammation rather than part of the primary cystic fibrosis defect. The increase in gamma-GT in the CF-I group suggests a mechanism by which extracellular glutathione could be utilised by airway epithelial cells.

Mutations in shaking-B prevent electrical synapse formation in the Drosophila giant fiber system

The giant fiber system (GFS) is a simple network of neurons that mediates visually elicited escape behavior in Drosophila. The giant fiber (GF), the major component of the system, is a large, descending interneuron that relays visual stimuli to the motoneurons that innervate the tergotrochanteral jump muscle (TTM) and dorsal longitudinal flight muscles (DLMs). Mutations in the neural transcript from the shaking-B locus abolish the behavioral response by disrupting transmission at some electrical synapses in the GFS. This study focuses on the role of the gene in the development of the synaptic connections. Using an enhancer-trap line that expresses lacZ in the GFs, we show that the neurons develop during the first 30 hr of metamorphosis. Within the next 15 hr, they begin to form electrical synapses, as indicated by the transfer of intracellularly injected Lucifer yellow. The GFs dye-couple to the TTM motoneuron between 30 and 45 hr of metamorphosis, to the peripherally synapsing interneuron that drives the DLM motoneurons at approximately 48 hr, and to giant commissural interneurons in the brain at approximately 55 hr. Immunocytochemistry with shaking-B peptide antisera demonstrates that the expression of shaking-B protein in the region of GFS synapses coincides temporally with the onset of synaptogenesis; expression persists thereafter. The mutation shak-B2, which eliminates protein expression, prevents the establishment of dye coupling shaking-B, therefore, is essential for the assembly and/or maintenance of functional gap junctions at electrical synapses in the GFS.

Effect of magnetic field strength on the linewidth and spin-lattice relaxation time of the thiocyanate carbon of cyanylated beta-lactoglobulin B: optimization of the experimental parameters for observing thiocyanate carbons in proteins

The linewidths and spin-lattice relaxation times of the 13C-n.m.r. signal at 109.7 p.p.m. due to the thiocyanate carbon of intact [cyanato-13C]cyanylated-beta-lactoglobulin-B have been determined at magnetic field strengths of 1.88, 6.34 and 11.74 T as well as the spin-lattice relaxation times of its backbone alpha-carbon atoms. The linewidths were directly proportional to the square of the magnetic field strength and we conclude that, at magnetic field strengths of 6.34 T or above, more than 70% of the linewidth will be determined by chemical-shift anisotropy. We estimate that the spin-lattice relaxation time resulting from the chemical-shift anisotropy of the thiocyanate carbon is 1.52 +/- 0.1 s and we conclude that for magnetic field strengths of 6.34 T and above the observed spin-lattice relaxation time of the thiocyanate carbon will be essentially independent of magnetic field strength. Using the rigid-rotor model we obtain estimates of the rotational correlation time of [cyanato-13C]cyanylated-beta-lactoglobulin-B and of the chemical-shift anisotropy shielding tensor of its thiocyanate carbon. We have calculated the linewidths and spin-lattice relaxation times of thiocyanate carbons at magnetic field strengths of 1.88-14.1 T in proteins with M(r) values in the range 10,000-400,000. The effects of magnetic field strength on the resolution and signal-to-noise ratios of the signals due to thiocyanate carbons attached to proteins of M(r) greater than 10,000 are discussed.

Gender differences in lung growth

Annual measurements of lung volumes and forced expiratory flows were made in 281 boys and girls from 8 to 12 years and in another cohort of 287 from 12 to 20 years to measure longitudinal lung growth. Gender differences in growth of lung function were documented, with girls generating greater volume-standardized maximal expiratory flows until age 18.5 years. Beyond that age boys generated higher expiratory flows in proportion to total lung capacity (TLC). There was a time lag of up to 1 year between the age of peak growth velocity in lung volume and peak growth velocity in height. Age at peak growth in flow lagged another year behind that in volume. This was noted more in boys than girls. Dysanaptic lung growth was found with differing rates of growth of maximal expiratory flow compared with TLC or vital capacity (VC).

Incest and its meaning: the perspectives of fathers and daughters

This article describes incestuous events and the structure of meaning surrounding the events by biologic fathers and stepfathers and biologic daughters and stepdaughters. Using a symbolic interaction framework the study is guided by the thesis that the meanings people attach to incestuous events are central to understanding the phenomena of incest. Data were obtained from indepth interviews with 40 men (14 natural fathers and 26 stepfathers) and 44 children (18 biologic daughters and 26 stepdaughters). The interviews emphasized fathers' and daughters' recollection of events and their thoughts and interpretations of the incestuous activity while it was occurring. Both fathers and daughters reported that the sexual activity grew out of already existing family interactions. However, fathers and daughters' cognitions surrounding the events differed dramatically. Many of the fathers said their thoughts were dominated by themes of sexual gratification, control, power and anger, and rights and responsibilities vis-à-vis their role as father or stepfather. Daughters reported disbelief, confusion, guilt, and anger. According to fathers, they completely misread their child's reaction to what was happening. Although fathers said that they knew what they were doing was wrong, few reported that they were concerned with possible legal consequences.

13C-n.m.r. of the cyanylated beta-lactoglobulins: evidence that Cys-121 provides the thiol group of beta-lactoglobulins A and B

The thiol groups of beta-lactoglobulins A and B have been cyanylated using [13C]KCN. The samples of [cyanato-13C]-cyanylated-beta-lactoglobulins A and B which we prepared had signals at 109.7 p.p.m. and 114.4 p.p.m. We conclude that the thiocyanate carbon having a chemical shift of 109.7 p.p.m. is in an apolar environment similar to a cyclohexane solvent, whereas the thiocyanate carbon having a chemical shift of 114.4 p.p.m. is in a polar environment similar to water. The signals with chemical shifts of 109.7 p.p.m. are assigned to the thiocyanate carbons of the native [cyanato-13C]cyanylated-beta-lactoglobulins A and B. We deduce that the signal at 114.4 p.p.m. is due to an irreversibly denatured/unfolded species produced by alkaline denaturation, which is caused by intramolecular thiol/disulphide exchange occurring during our cyanylation procedure. We propose that Cys-119 is cyanylated in the irreversibly denatured species and Cys-121 is cyanylated in the native [cyanato-13C]cyanylated-beta-lactoglobulins A and B. We suggest that the same intramolecular thiol-disulphide exchange reactions occurred when McKenzie and co-workers [McKenzie, Ralston and Shaw (1972) Biochemistry 11, 4539-4547] alkylated beta-lactoglobulins with iodoacetamide. Therefore the one mol of thiol/mol of monomer in the native beta-lactoglobulins is due to the thiol of Cys-121 and is not due to an equimolar mixture of Cys-119 and Cys-121 as they suggested.

Characterisation of high-affinity and low-affinity receptors for ciliary neurotrophic factor

Ciliary neurotrophic factor (CNTF) supports the survival of a wide variety of neuronal cells in culture. To characterise the receptor(s) mediating the biological responses of CNTF we measured the binding of radiolabelled CNTF to chick sympathetic neurons and human neuroblastoma cells. Two distinct CNTF-binding sites with high and low affinity for the ligand were identified by steady-state binding experiments. Furthermore, two low-affinity binding sites could be discriminated on the basis of the dissociation rates. Cross-linking experiments showed that CNTF interacts with two proteins, one of 80 kDa and one of 140 kDa. The identity of the 80-kDa protein was determined by transient transfection experiments with the rat CNTF-binding protein CNTFR alpha while the properties of the 140-kDa protein correspond to those of gp130. Antisense experiments confirmed that CNTFR alpha is necessary for high affinity binding of 125I-CNTF and therefore a necessary subunit of the high-affinity receptor.

Primary nursing part time

Although I agreed with the views expressed by Linda Nazarko in her article 'Primary or secondary' (Viewpoint, March 11), I was horrified by her example of the nurse who was rejected as a primary nurse because she worked part time.

Assessment and treatment of childhood asthma

In June 1990 a meeting of Paediatric Respiratory Physicians was held near Adelaide. The guidelines for assessing and treating asthma as prepared by the Thoracic Society of Australia and New Zealand for the management of patients with asthma was considered. Although not explicitly stated, these guidelines were designed for adult asthmatics. There was complete agreement that a companion statement was needed to take into account differences between the management of children and adults. This document fulfils that role. Further recommendations are found in a statement prepared by Australian and New Zealand respiratory paediatricians following a workshop in June 1989. This present statement should be read in association with the previous documents.

The problem of neonatal diagnosis related groups

There is, as yet, no satisfactory set of Diagnosis Related Groups to measure the casemix and consumption of hospital resources in the care of newborn infants. To obtain further information, infants less than 28 days when admitted to the Royal Children's Hospital and Royal Women's Hospital, Melbourne were analysed. Both Refined Diagnosis Related Groups and Pediatric Modified Diagnosis Groups were used. Neonatal groups of the Pediatric Modified system included all infants aged less than 28 days on admission, whereas Refined Diagnosis Related Groups includes only those newborn infants who have diagnoses specific to the newborn period. Refined Diagnosis Related Groups and their higher order contained 1,237 discharges. Standard deviation and coefficient of variation and length of stay in these RDRG were high. However, if the patients in these RDRGs were further grouped according to PMDRGs, there appeared to be more homogeneous missing. The R2 values were four times higher. It is recommended that a satisfactory form of neonatal DRGs is to regroup patients in neonatal RDRGs through a PMDRG grouper.

Steroids in croup: do they increase the incidence of successful extubation?

Between January 1983 and July 1988, 2623 patients with croup were admitted to the Royal Children's Hospital, Melbourne. A total of 416 patients (16%) were admitted to the Intensive Care Unit and 176 of these patients required intubation. Of these patients 117 patients were successfully extubated at the first attempt and 59 needed reintubation. Of the patients who were reintubated 35 were given steroids prior to subsequent extubation attempts. Only one patient who had received steroids failed extubation. Of those who did not receive steroids 59% required reintubation. In patients with croup who fail the first extubation the results of this study suggest that steroids significantly increase the success of subsequent extubations.

Diagnosis related groups, refined diagnosis related groups and pediatric modified diagnosis related groups in specialist children's hospitals

The value of Diagnosis Related Groups, Refinement Diagnosis Related Groups and Pediatric Modified Diagnosis Related Groups in measuring the output of specialist children's hospitals was evaluated by the examination of discharge data for 1987-88 from three major Australian children's hospitals and four district hospitals. The study included all patients aged 0-18 years but excluded those with specific neonatal diagnoses. Findings indicated that Refinement Diagnosis Related Groups seem to give a better measure of the output of specialist children's hospitals than Version 5 Diagnosis Related Groups in that they explained a higher proportion of variation of length of stay. Pediatric Modified Diagnosis Related Groups developed in the United States of America for specialist children's hospitals overall did not seem to have major advantages over Refinement Diagnosis Related Groups but there were some specific Pediatric Groups that appeared beneficial. Further modification of the Refinement Diagnosis Related Groups could allow these advantages to be incorporated. Overall it seems preferable for there to be a similar system measuring output of both children's hospitals and general hospitals and this could be achieved by some minor changes to the Refinement Diagnosis Related Groups.

Acute epiglottitis: a different approach to management

Between January 1979 and October 1986, 349 patients with epiglottitis were admitted to the Royal Children's Hospital, Melbourne, Australia. Forty-five (13%) patients were not intubated, 291 (83%) were managed by nasotracheal intubation and spontaneous respiration without sedation, three (1%) received continuous positive airway pressure, and ten (3%) were ventilated. The 294 patients who were not ventilated were intubated for a mean of 18 +/- 9.5 (SD) h; 90% were extubated within 24 h. Criteria for extubation included resolution of fever (less than 37.5 degrees C), passage of time (12 to 16 h), and improvement in the general appearance of the child. Laryngoscopy was not performed before extubation. Providing there is always a doctor present who can reintubate if accidental extubation occurs, routine use of sedation, paralysis and mechanical ventilation, and pre-extubation laryngoscopy are not required for the management of children with uncomplicated epiglottitis, and their use may prolong the period of intubation.

Snoring in children: is it pathological?

Some children who snore heavily, have been shown to have periods of apnoea which, if frequent, are known as the obstructive sleep apnoea syndrome (OSA). Twenty patients with OSA, who presented to the Department of Thoracic Medicine, Royal Children's Hospital, Melbourne, over a three-year period, were reviewed. The findings indicated that OSA is more common than is generally supposed and that it can present with a wide range of symptoms. It is important that an early diagnosis of this syndrome is made, to prevent major complications and to allow appropriate therapy.

Sodium valproate stimulates the particulate form of glutamine synthetase in rat brain

The anticonvulsant drug, sodium valproate, enhanced total activity of glutamine synthetase in cortical and cerebellar homogenates of the rat at concentrations of 25-50 mM, without significantly altering substrate affinity. This effect was due to a selective increase in the Vmax and substrate affinity of the enzyme in the particulate fraction. At the same concentration the drug caused little change in the Vmax of the cytosolic enzyme, although the substrate affinity was reduced. These effects cannot be attributed to isozymes of glutamine synthetase as only one form could be demonstrated by ion-exchange chromatography or electroblotting with antibodies to glutamine synthetase. This selective stimulation of particulate glutamine synthetase is suggested to be due to increases in membrane fluidity induced by the drug. The contribution of these effects to the mechanistic action of sodium valproate is discussed.

Cystic fibrosis mortality in England and Wales and in Victoria, Australia 1976-80

Mortality from cystic fibrosis throughout childhood is more than twice as high in England and Wales than it is in the State of Victoria, Australia. Possible reasons for this difference are reviewed.

Progressive inflammatory subglottic narrowing responsive to steroids

Four children aged between 2½ and 13½ years developed insidious subglottic stenosis of unknown cause over 3-12 months. In all, the initial diagnosis was asthma which resulted in inappropriate treatment. Endoscopically there was circumferential subglottic narrowing, and biopsy in 3 showed non-specific inflammatory changes. Corticosteroid therapy led to rapid and complete resolution.