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.

Novel Class of Rhenium Borides Based on Hexagonal Boron Networks Interconnected by Short B2 Dumbbells

Transition metal borides are known due to their attractive mechanical, electronic, refractive, and other properties. A new class of rhenium borides was identified by synchrotron single-crystal X-ray diffraction experiments in laser-heated diamond anvil cells between 26 and 75 GPa. Recoverable to ambient conditions, compounds rhenium triboride (ReB₃) and rhenium tetraboride (ReB₄) consist of close-packed single layers of rhenium atoms alternating with boron networks built from puckered hexagonal layers, which link short bonded (∼1.7 Å) axially oriented B₂ dumbbells. The short and incompressible Re-B and B-B bonds oriented along the hexagonal c-axis contribute to low axial compressibility comparable with the linear compressibility of diamond. Sub-millimeter samples of ReB₃ and ReB₄ were synthesized in a large-volume press at pressures as low as 33 GPa and used for material characterization. Crystals of both compounds are metallic and hard (Vickers hardness, H _V = 34(3) GPa). Geometrical, crystal-chemical, and theoretical analysis considerations suggest that potential ReB _x compounds with x > 4 can be based on the same principle of structural organization as in ReB₃ and ReB₄ and possess similar mechanical and electronic properties.

Neuroinflammatory and morphological changes in late-life depression: the NIMROD study

We studied neuroinflammation in individuals with late-life depression, as a risk factor for dementia, using [¹¹C]PK11195 positron emission tomography (PET). Five older participants with major depression and 13 controls underwent PET and multimodal 3T magnetic resonance imaging (MRI), with blood taken to measure C-reactive protein (CRP). We found significantly higher CRP levels in those with late-life depression and raised [¹¹C]PK11195 binding compared with controls in brain regions associated with depression, including subgenual anterior cingulate cortex, and significant hippocampal subfield atrophy in cornu ammonis 1 and subiculum. Our findings suggest neuroinflammation requires further investigation in late-life depression, both as a possible aetiological factor and a potential therapeutic target.

Protein phosphatases 1 and 2A maintain endothelial cells in a resting state, limiting the motility that is needed for the morphogenic process of angiogenesis

Angiogenesis that is induced by cancers, including those of the head and neck, requires endothelial cells to shift from a nonmotile resting state to an increased level of motility. Using a human microvascular endothelial cell line, this study shows the importance of the serine/threonine protein phosphatases 1 (PP1) and 2A (PP2A) in restricting endothelial cell motility. Treatment of endothelial cells with increasing concentrations of the PP1 and PP2A inhibitor okadaic acid resulted in cell rounding and increased motility, which was accompanied by cytoskeletal disorganization involving a loss of filamentous beta-tubulin and F-actin. These effects occurred at okadaic acid levels that selectively inhibit PP2A and became more prominent with higher levels that inhibit both PP2A and PP1. This study shows the importance of PP1 and PP2A in maintaining cytoskeletal organization, thereby limiting endothelial cell motility, and suggests that pharmacologic approaches to enhance PP1 and PP2A activities may be useful in preventing key events of the angiogenic process.

Personality dimensions and substance misuse: relationships in adolescents, mothers and fathers

The research addressed the question of whether relationships exist between personality dimensions, antisocial behavior, and alcohol or other substance misuse (AOSM) in adolescents and in their fathers and mothers, who often also have histories of AOSM. One hundred male adolescents (mean age 15.8 years) entering a residential treatment center for youths with AOSM, their mothers (n = 88, mean age 39.4 years), their fathers (n = 36, mean age 44.9 years), and community controls (n = 100 adolescents, mean age 16.5 years; n = 96 mothers, mean age 43.8 years; n = 87 fathers, mean age 45.9 years) were recruited. All participants completed a personality questionnaire and were interviewed on several measures, including structured interviews for psychopathology and substance misuse. The findings indicated that novelty seeking (NS), one of the personality dimensions, was significantly correlated with substance misuse in adolescent probands, adolescent controls, and proband fathers and mothers, but not in control fathers and mothers. Regression analyses that included conduct disorder (CD) or antisocial personality disorder (APD) symptoms indicated that both NS and CD or APD symptoms made significant contributions to the prediction of substance misuse in treatment group probands and in their fathers and mothers. The findings further suggest that NS and antisocial behaviors contribute independently to substance misuse in severely impaired adolescents and their fathers, but not in their mothers.

Leadership in the managed care era: challenges, conflict, ambivalence

Mental health organizations are in the midst of massive changes brought about by managed care. This paper explores attitudes and reactions of leaders in mental health organizations to these changes. The leader's own conflicts regarding this approach to mental health care is a major determinant of why some organizations adapt more readily than others. Strategies for leaders that recognize the need to address conflict within the individual and the organization are discussed. The importance of facilitating dynamic interactional processes between leaders and non-leaders in regard to mutual expectations also is emphasized.

Family variables in substance-misusing male adolescents: the importance of maternal disorder

Selected family variables, especially maternal behaviors, were studied as predictors of alcohol and drug misuse in severely disturbed adolescent boys from largely father-absent homes. The families of 50 male youths (mean age 15.8 years) in a residential center for alcohol and substance misuse were compared with the families of a community control group (mean age 16.3 years). Within-subject group comparisons also were made. Family structure, interactive processes, maternal and paternal alcohol and substance use, and criminality were assessed through direct interview and/or self-report. The families of alcohol- and substance-misusing boys were markedly disadvantaged or impaired on numerous family structure, process, and substance-misusing behavioral variables in comparison with community controls. Within the alcohol- and substance-misusing group itself, family process variables, maternal alcohol symptoms, and maternal criminality differentiated boys with more vs. less severe drug-dependence symptoms. Maternal alcohol problems and criminality were more important than family process variables. Paternal alcohol or substance misuse or criminality did not differentiate proband symptom severity. We concluded that maternal alcohol symptoms and criminality differentiate severity of drug dependence in severely disturbed, substance-misusing adolescent males from largely father-absent homes. Maternal substance misuse should be evaluated carefully in adolescent substance abuse treatment settings.

Mental health providers confronting organizational change: process, problems, and strategies

Under the influence of managed care and diminished funding, the mental health field is undergoing a major transformation. Existing mental health programs, departments, and agencies are downsizing and restructuring to develop new types of service delivery systems. Organizations must change to survive; yet necessary and adaptive change may be resisted in numerous ways by providers whose reactions and behaviors may reduce the viability of their own programs and agencies. This paper explores various characteristics and reactions of mental health care professionals as they face great stress, professional devaluation, and necessary organizational change and restructuring. Adaptive and maladaptive patterns in response to potential organizational change are explored. The role of the leader in guiding and implementing programmatic changes and in dealing with denial and resistance is highlighted. Strategies to enhance the prospects for adaptive organizational change are offered.

Molecular cloning, expression, and functional significance of a cytochrome P450 highly expressed in rat heart myocytes

A cDNA encoding a P450 monooxygenase was amplified from reverse transcribed rat heart and liver total RNA by polymerase chain reaction using primers based on the 5'- and 3'-end sequences of two rat pseudogenes, CYP2J3P1 and CYP2J3P2. Sequence analysis revealed that this 1,778-base pair cDNA contained an open reading frame and encoded a new 502 amino acid protein designated CYP2J3. Based on the deduced amino acid sequence, CYP2J3 was approximately 70% homologous to both human CYP2J2 and rabbit CYP2J1. Recombinant CYP2J3 protein was co-expressed with NADPH-cytochrome P450 oxidoreductase in Sf9 insect cells using a baculovirus expression system. Microsomal fractions of CYP2J3/NADPH-cytochrome P450 oxidoreductase-transfected cells metabolized arachidonic acid to 14,15-, 11,12-, and 8, 9-epoxyeicosatrienoic acids and 19-hydroxyeicosatetraenoic acid as the principal reaction products (catalytic turnover, 0.2 nmol of product/nmol of cytochrome P450/min at 37 degrees C). Immunoblotting of microsomal fractions prepared from rat tissues using a polyclonal antibody raised against recombinant CYP2J2 that cross-reacted with CYP2J3 but not with other known rat P450s demonstrated abundant expression of CYP2J3 protein in heart and liver. Immunohistochemical staining of formalin-fixed paraffin-embedded rat heart tissue sections using the anti-CYP2J2 IgG and avidin-biotin-peroxidase detection localized expression of CYP2J3 primarily to atrial and ventricular myocytes. In an isolated-perfused rat heart model, 20 min of global ischemia followed by 40 min of reflow resulted in recovery of only 44 +/- 6% of base-line contractile function. The addition of 5 microM 11, 12-epoxyeicosatrienoic acid to the perfusate prior to global ischemia resulted in a significant 1.6-fold improvement in recovery of cardiac contractility (69 +/- 5% of base line, p = 0.01 versus vehicle alone). Importantly, neither 14,15-epoxyeicosatrienoic acid nor 19-hydroxyeicosatetraenoic acid significantly improved functional recovery following global ischemia, demonstrating the specificity of the biological effect for the 11, 12-epoxyeicosatrienoic acid regioisomer. Based on these data, we conclude that (a) CYP2J3 is one of the predominant enzymes responsible for the oxidation of endogenous arachidonic acid pools in rat heart myocytes and (b) 11,12-epoxyeicosatrienoic acid may play an important functional role in the response of the heart to ischemia.

Comorbidity in hyperactive children: issues related to selection bias, gender, severity, and internalizing symptoms

Parental behavior ratings of hyperactive boys and girls aged 6-11 years seen for evaluation in a general outpatient child psychiatry clinic and in a specialty "attention deficit disorder" (ADD) program were analyzed. The pattern of comorbidity in the two groups showed no significant differences. Most of the associated internalizing and externalizing behavioral scales in hyperactive boys and in hyperactive girls were elevated and in clinical ranges except for the "somatic complaints" scale. Comorbidity in both hyperactive boys and girls was related to the severity of the hyperactivity itself.

Homovanillic acid and dopamine-beta-hydroxylase in male youth: relationships with paternal substance abuse and antisocial behavior

Recent research suggests that dopaminergic/noradrenergic system dysfunction may be associated with substance abuse and/or antisocial behavior. In order to determine whether male youth of fathers with these disorders would manifest differences in these systems when compared with youth of nonsubstance-abusing or nonantisocial fathers, levels of homovanillic acid (HVA), the metabolite of dopamine (DA) and dopamine-beta-hydroxylase (DBH), the enzyme facilitating the conversion of dopamine to norepineprhine, were studied in offspring blood samples. The subjects were 65 male youth aged 6-15 years admitted to a residential center because of behavioral disorders. Parental substance abuse and antisocial behavior were assessed through interviews, rating scales, and/or chart review. HVA and DBH were determined from blood samples obtained after admission. The findings indicated that youth of substance-abusing fathers had significantly greater levels of HVA than yough of nonsubstance-abusing fathers. Younger (< 12.0 years) boys of antisocial fathers had significantly lower DBH activity than comparably aged youth of nonantisocial fathers. The results suggest that common generational links in substance abuse and antisocial behavior in males may be associated with detectable biological parameters in susceptible youth.

A redox-based mechanism for cardioprotection induced by ischemic preconditioning in perfused rat heart

Recent studies have suggested that mild redox alterations can regulate cell function. Therefore, we tested the hypothesis that alteration in the thiol redox state might be responsible for the cardioprotective effects conferred by ischemic preconditioning in the perfused rat heart. We find that preconditioning with four 5-minute periods of ischemia, each separated by 5 minutes of reflow, is associated with a significant loss of glutathione (3.98 +/- 0.32 mumol/g dry wt, n = 8) compared with no preconditioning (6.38 +/- 0.24 mumol/g dry wt, n = 14). We further find that the addition of N-acetylcysteine (NAC, a glutathione precursor and antioxidant) during the preconditioning protocol not only blocks the loss of glutathione (5.60 +/- 0.31 mumol/g dry wt, n = 9) but also blocks the protective effects of preconditioning. It is observed that after 20 minutes of ischemia followed by 20 minutes of reflow, untreated hearts recover 38 +/- 7% (n = 5) of their initial preischemic contractile function, whereas preconditioned hearts recover 91 +/- 11% (n = 7). Hearts preconditioned in the presence of NAC recover 24 +/- 3% (n = 7) of their preischemic function. Similarly, the addition of NAC reverses the protective effect of preconditioning on creatine kinase release. On reflow after 60 minutes of ischemia, creatine kinase release from control hearts was 271 +/- 20 IU.20 min-1.g dry wt-1 (n = 5), whereas preconditioned hearts release only 170 +/- 26 IU.20 min-1.g dry wt-1 (n = 6), and hearts preconditioned in the presence of NAC release 361 +/- 30 IU.20 min-1.g dry wt-1 (n = 5). We also find that hearts preconditioned in the presence of NAC have less attenuation of the decline in pHi than hearts preconditioned in the absence of drug. Thus, a redox-sensitive mechanism may be involved in the protection afforded by ischemic preconditioning.

Homovanillic acid and monoamine oxidase in sons of substance-abusing fathers: relationship to conduct disorder

OBJECTIVE

Children of substance-abusing (SA) fathers have been found to have increased rates of conduct disorder (CD). Substance abuse and antisocial behavior have been linked to alterations in dopaminergic regulation and to monoamine oxidase (MAO) in adults. This study assessed the relationship between homovanillic acid (HVA), the metabolite of dopamine (DA), and MAO, the enzyme facilitating the conversion of DA to HVA, with CD in boys of SA and non-SA fathers.

METHOD

Male youths (N = 65), between the ages of 6 and 15 years, admitted to a residential setting because of behavior problems, were studied through peripheral blood samples and structured interviews.

RESULTS

The findings indicated that MAO activity was significantly higher in boys of SA fathers with CD than (1) in boys of non-SA fathers with CD and (2) in boys of SA fathers without CD. HVA levels did not differ significantly among the groups.

CONCLUSIONS

In the context of previous studies, the findings support the concept of dopaminergic dysregulation in sons of SA fathers, manifested by alterations in MAO activity levels in those youths with CD.

Monoamine oxidase and homovanillic acid in boys with predispositions to substance abuse

Both dopaminergic dysregulation and abnormalities in monoamine oxidase (MAO) have been postulated as etiological factors in substance abuse. This study assessed whether MAO activity differed in sons of substance-abusing fathers compared with sons of nonsubstance-abusing fathers. It also assessed the levels of homovanillic acid (HVA), the metabolite of dopamine, and MAO in a group of substance-using/-abusing boys compared with peers without this history in the same setting. Sixty-five boys admitted to a residential center were evaluated on blood tests for HVA and MAO, and on a series of diagnostic instruments and questionnaires designed to elicit information about parental substance abuse and about the subject's own substance use/abuse. The results indicated tentatively that younger (< 12.0 years) sons of substance-abusing fathers had higher levels of MAO than younger sons of nonsubstance-abusing fathers. Levels of MAO in older (> or = 12.0 years) sons of substance-abusing and nonsubstance-abusing fathers did not differ. Boys with histories of significant use/abuse of substances themselves had significantly higher MAO levels and significantly lower HVA levels than peers of the same age without substance use/abuse histories.

Neglected rupture of the Achilles tendon

Delayed treatment of a rupture of the Achilles tendon is a challenge. Operative treatment is generally recommended, with a variety of techniques being described to appose the tendinous ends and augment the repair.

Measurement of cytosolic free calcium in perfused rat heart using TF-BAPTA

The feasibility and usefulness of loading 1,2-bis(2-amino-5,6-difluorophenoxy)ethane-N,N,N',N'-tetraacetic acid (TF-BAPTA), a new high-dissociation constant (KD) (65 microM) Ca2+ indicator, into perfused rat heart is demonstrated. TF-BAPTA-loaded perfused rat heart showed less than a 10% reduction in left ventricular developed pressure. In addition, loading perfused rat heart with TF-BAPTA had no effect on cell high-energy phosphates measured by 31P-nuclear magnetic resonance (NMR). Cytosolic free Ca2+ (Ca2+i) can be monitored in TF-BAPTA-loaded perfused rat heart using 19F-NMR. TF-BAPTA has a Ca(2+)-insensitive resonance (6F) and a Ca(2+)-sensitive fluorine (5F) that responds to changes in Ca2+ binding with fast exchange kinetics at magnetic fields < or = 8.5 T. Thus the shift difference between the 5F and 6F resonances is a measure of Ca2+i. Given the high KD and the slight differences in intra- vs. extracellular fluorine shifts, TF-BAPTA is not well suited for measuring basal Ca2+i, but it is useful for measuring increases in Ca2+i above this level. For studies in which intracellular pH changes are significant, e.g., during ischemia, pH-dependent corrections must be made to obtain an accurate Ca2+i value. Given its fast exchange kinetics, TF-BAPTA is also useful for measurement of free Ca2+ in different compartments or cells with different Ca2+i. We show that the rise in Ca2+i is not uniform during prolonged global ischemia (60 min); several different Ca2+i values are present. Thus TF-BAPTA is a useful new indicator for measuring elevations in Ca2+i or compartmentation of Ca2+i.(ABSTRACT TRUNCATED AT 250 WORDS)

NMR-sensitive fluorinated and fluorescent intracellular calcium ion indicators with high dissociation constants

A new series of high-dissociation constant (KD) Ca2+ indicators has been developed to reduce perturbations due to buffering of transients, to carry out measurements in cells and organelles with high basal Ca2+ concentrations, and to measure cytosolic Ca2+ levels in the presence of perturbations that may significantly increase these levels. A tetrafluorinated derivative of the chelator 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid, 1,2-bis(2-amino-5,6-difluorophenoxy)ethane-N,N,N',N'-tetraacetic acid (TF-BAPTA), has a KD of 65 microM and exhibits two fluorine nuclear magnetic resonances, one of which is insensitive to Ca2+ chelation and the second of which shifts by approximately 10 ppm upon Ca2+ binding. TF-BAPTA has pK values of approximately 5.0 and Mg2+ dissociation constants > 50 mM. At a field of 8.5 T, the Ca(2+)-sensitive resonance is in fast-intermediate exchange. Correction factors for the effects of intermediate exchange and for the effect of protonation (pK approximately 5.0) and Mg2+ complexation are discussed. An analogous approach has been used to synthesize 2-[2-(5-carboxyoxazole)]-5-[2-(2-bis(carboxymethyl) amino-5,6-difluorophenoxy)]ethoxy-6-bis(carboxymethyl)aminobenz ofuran (fura F), a structural analogue of fura 2, which exhibits fluorescence characteristics similar to those of fura 2, but has a KD of 20 microM.

Variations in countertransference reactions in psychotherapy with children

This paper has further developed and argued for a broadened concept of countertransference in psychotherapy with children and adolescents. The model presented here emphasizes that countertransference difficulties may result because of therapist reactions (1) to the child that are acted upon directly in the child's treatment, (2) that are stimulated by the child and displaced onto parents, or (3) that are stimulated by the parents themselves, while still being acted upon in the treatment of the child. In all of these situations, the therapist unconsciously may alter the treatment of the child or the guidance offered the parents about the child. Supervision and consultation in therapy, as well as therapists' examination of their own reactions to all members of the family system (including to those who are not present) are helpful in understanding and managing these complicated countertransference reactions. Finally, it is highly recommended that therapists see parents of a child in treatment regularly to decrease distortions of them and to appreciate them appropriately as ordinary human beings.

Sensation seeking in psychiatrically disturbed youth: relationship to biochemical parameters and behavior problems

OBJECTIVE

Relatively little research has been conducted on the relationship of personality traits or behavioral tendencies with biological parameters in youth. This study was intended to determine whether relationships exist between self-reported sensation-seeking tendencies and biochemical parameters in boys.

METHOD

Twenty-five male youth aged 8 to 15 years admitted to a residential diagnostic center because of noncompliant, disruptive, and/or antisocial behavior were studied. Biochemical parameters associated with sensation seeking in adults or antisocial behavior were measured along with diagnoses, behavior ratings, and self-reported sensation seeking.

RESULTS

High sensation seeking, as assessed on a newly developed sensation-seeking scale for children, was inversely correlated with 3-methoxy-4-hydroxyphenylglycol (MHPG) levels in the older youth (> or = 12.0 years) but not in the younger boys (< 12.0 years) in the group. Elevations on the sensation seeking scale also correlated marginally in these older youth with parent-reported problems on a behavior rating scale, reflecting "delinquent" behavioral tendencies.

CONCLUSIONS

The findings support hypothesized noradrenergic dysregulation in some sensation-seeking persons (including youth > or = 12.0 years) and the relationship between high sensation-seeking tendencies and antisocial or disruptive behavioral disorder.

Dopamine-beta-hydroxylase in behaviorally disturbed youth. Relationship between teacher and parent ratings

A series of neurotransmitters, metabolites, and enzymes considered relevant to emotional and behavioral disorders was studied in blood samples obtained from boys admitted to a residential setting because of disruptive or unmanageable behavior in their home environments. The youth were categorized into mainly prepubertal (under 12.0 years) and pubertal/post pubertal (12.0 years and over) groups. Behavior ratings of the younger group completed by parents revealed significant inverse correlations between several behavioral factors and dopamine-beta-hydroxylase (DBH) activity levels, notably in the aggressive behavior and antisocial domains. Teacher ratings completed after about 1 month of living in the residential setting also showed numerous significant, but positive, correlations between several behavior factors and DBH activity levels. Furthermore, teacher and parent ratings themselves often were significantly and inversely correlated. The findings related to DBH activity levels were strongest in the younger group of boys. The results are discussed in terms of the possibility that low DBH activity in boys reflects a vulnerability towards behavioral disorder, which in certain environments becomes manifested by conduct problems and antisocial behavior.

The phenomenology of the self and its objects in waking and dreaming: implications for a model of dreaming

The current psychoanalytic emphasis on self psychology allows attention to be drawn to the nature of the self, internal and external object representations, and possibilities involving the self in relationship to aspects of self and objects in dreams. An emphasis on the self, applied to dreams, appears to fit well with current concepts of REM sleep that involve this sleep stage's importance for the individual in learning, adaptation, and assimilation of emotionally meaningful information. Examples have been provided to indicate possible contributions of self psychological perspectives to an understanding of dreams. A model describing changes in the self and its objects in dream mentation compared to the self and its objects in waking mentation has been described. The model suggests that the self of the dream relates to separated off, changed, or newly cathected attitudes, beliefs, and object representations in a manner that describes the state of the individual and possibilities for change available to the individual. This model, having historical roots in Jungian psychology, adaptive/learning theories of REM sleep, and current Kohutian initiated self-state dream theory, provides an opportunity to review with the dreamer the relationships of self and objects as these representations are concerned with problematic developmental or emotional situations.

Characteristics of children whose parents have been incarcerated

OBJECTIVE

The study sought to determine the relationship between parental incarceration and behavioral and family characteristics among children in a day hospital.

METHODS

Chi square analysis and t tests were used to compare preadmission characteristics and teachers' behavioral ratings of a group of 16 children in a day hospital setting who had experienced the incarceration of one or both parents and a group of 21 children in that setting who had no history of parental incarceration.

RESULTS

Children in the parental incarceration group were significantly more likely to have experienced parental substance abuse than those whose parents had not been incarcerated. A history of child abuse or maltreatment appeared to be more likely among the parental incarceration group. Boys whose fathers had been incarcerated received higher teacher ratings of delinquent and aggressive behavior. Paternal incarceration among girls was associated with a significant increase in attention problems.

CONCLUSIONS

A history of parental incarceration may be quite common in some mental health samples of children. It appears to be associated with severe family dysfunction and behavioral disorders.

Biodevelopmental aspects of conduct disorder in boys

The association between biochemical parameters and conduct disorder (CD) was studied in 22 boys admitted to a residential center. Three-methoxy-4-hydroxyphenylglycol (MHPG) levels were significantly higher in prepubertal CD youth than in pubertal/post pubertal CD youth. Homovanillic acid (HVA) levels were significantly lower in CD youth under age 12.0 years than in non CD youth under age 12.0 years. The implications of these biodevelopmental findings in the study of CD are discussed.

Incarceration in parents of day hospital youth: relationship to parental substance abuse and suspected child abuse/maltreatment

The number of individuals incarcerated in penal institutions in the United States has increased dramatically in recent years. Children of incarcerated parents have been studied infrequently. They appear to be at high risk for present and future behavioral disorders, although their rate of utilization of mental health services is not known. This study compares a group of behaviorally disturbed children in day hospital treatment who have had incarcerated parents with a group of children without this history who were treated in the same facility at the same time. Children with histories of incarcerated parents account for almost 40% of those treated. They are more likely than their peers without histories of having had an incarcerated parent to have had substance abusing parents and to have been involved in at least one report of suspected child abuse/maltreatment. These variables together are taken as signs of severe family disorganization or dysfunction. In previous studies they have also been associated with poor outcome in mental health treatment. Clinical and social implications of these findings are discussed.

Behavior problems in sons and daughters of substance abusing parents

Information to address the question of whether sex specific features exist in behavioral characteristics of children of substance abusing parents was gathered from the records of a large number of hospital treated youth. There was a trend for sons of substance abusing parents to have more conduct disorder diagnoses in association with severe aggressive/destructive behavior than sons of non substance abusing parents. Girls of substance abusing parents generally were more likely to have attention deficit/hyperactive, aggressive and conduct disorder problems than girls of non substance abusing parents.

Aggressive behavior in youth: characteristics, outcome, and psychiatric diagnoses

This study evaluated the characteristics and outcome of a group of children and adolescents treated in day hospital and inpatient settings. Severe aggressive/destructive behavior was present in about one-third of the sample and was more common in boys, in children and adolescents with history of parental substance abuse, and in those with a concurrent diagnosis of conduct disorder. Although both an admission diagnosis of conduct disorder and aggressive/destructive behavior as a preadmission variable predicted poor outcome, aggressive/destructive behavior was the more important of the two. Aggressive/destructive behavior in association with conduct disorder seems to confer an especially poor prognosis in hospital-treated youth.

Outcome in children's day treatment: relationship to preadmission variables

Outcome in children's day treatment has been studied infrequently. There is little information available to suggest which types of children may or may not benefit from day treatment services. In an earlier study, Gabel et al. (1988) found that preadmission factors related to parental/family dysfunction (i.e., suspected child abuse/maltreatment and parental substance abuse) and preadmission factors related to child dysfunction (i.e., suicidality and severe aggressive/destructive behavior) correlated with poor outcome in day treatment by the criterion of a recommended out-of-home placement on discharge. Of these factors, severe aggressive/destructive behavior was most important in predicting outcome. In this study, discharges from two additional centers were reviewed to determine if these findings could be generalized. There is support for the earlier results when the three centers' discharges are considered as a whole but not when the two new centers' discharges are considered separately. Reasons for these findings are discussed. Further study of these preadmission variables, especially severe aggressive/destructive behavior, as possible predictors of poor outcome in children's day treatment, seems warranted.

Parental substance abuse and suspected child abuse/maltreatment predict outcome in children's inpatient treatment

There has been relatively little empirical study of outcome for school aged children treated in psychiatric hospitals. In earlier studies, four preadmission variables were operationally defined and studied as hypothesized predictors of poor outcome in psychiatric day treatment by the criterion of recommended in-home or out-of-home placements on discharge. The preadmission variables are recent histories of severe aggression and suicidal ideation/behavior in the child and histories of parental substance abuse and reported suspicions of child abuse/maltreatment. In this study, the work has been extended to determine if these four preadmission factors relate to outcome of children treated in inpatient hospitalization. The findings indicate that the parent/family related variables, and not the child variables (nor child diagnosis), are significantly related to out-of-home recommended placements.

ATP, ADP, and magnesium mixed solutions: in vitro 31P NMR characterization and in vivo application to lens

The difference between the 31P NMR resonance position of the beta-peak of ADP and the gamma-peak of ATP at a fixed monovalent ion concentration level and pH is shown in vitro to depend only on free magnesium concentration. This difference can vary by more than 1 ppm depending on the pH of the solution and free magnesium concentration. Using 31P NMR and ion-selective electrodes we have constructed experimental curves to show how calibration of experimental results can be achieved. Theoretical calculations can be used to predict the functional dependence of the chemical shift difference on the above parameters. However, using the reported ion dissociation constants the fit was not exact and the discrepancy increased at higher pH values. To demonstrate that this technique can yield valid in vivo results and to analyze a previously unreported system where free magnesium levels vary, sample spectra from lenses and enucleated eyes are given. The data show a disagreement between the present methods and the more conventional ATP method. The reason for this difference is not known although some possible reasons are suggested.

Dreams as a possible reflection of a dissociated self-monitoring system

Recently, there has been a great deal of clinical and experimental interest expressed in dissociative disorders and dissociative states. Theories of mental organization and personality have been formulated as a result of this new emphasis on dissociative phenomena. Dreams may possibly be thought of as dissociative phenomena of a particular type that reflect a monitoring of and reaction to internal and external conditions within the dreamer. Experimental and/or clinical work related to hypnosis, rapid eye movement phenomena, dreams, and hemispheric specialization are discussed to support this view. Dreams are described within the context of dissociation-based theories of personality organization. Brain behavior relationships are emphasized whenever possible.

The right hemisphere in imagery, hypnosis, rapid eye movement sleep and dreaming. Empirical studies and tentative conclusions

Visual imagery, hypnosis, creativity, dreams, and "imagination" have all been linked conceptually by theoreticians of various schools to an increased influence of right hemispheric processes compared with left hemispheric processes. This paper reviews empirical studies that have addressed the issue of whether there is an increased activation or efficiency of right hemispheric processes during imagery, hypnosis, rapid eye movement sleep, and dreaming. Overall, there is considerable evidence supporting the notion of increased right hemispheric activation in imagery. There is also some evidence supporting this view for rapid eye movement sleep, dreaming, and hypnotic phenomena. For the most part, however, the lack of adequate studies, contradictory or negative findings, and moderating variables make it difficult to draw definitive conclusions at this time.

Behavioral ratings and outcome of medical treatment for encopresis

The relationship between behavior problems and encopresis remains controversial. Recent research suggests that children with encopresis do have numerous behavior problems, but that these problems are generally not as severe as the behavior problems found in children referred for mental health services. This study explores the relationship between baseline behavior ratings of encopretic boys, ages 6-11, on a standardized rating form, the Child Behavior Checklist (CBCL), and outcome of medical treatment for their encopresis. A strong correlation between the product of the sum of the factors on the internalizing scales and the sum of the factors on the externalizing scales and their interaction on the CBCL was associated with outcome. Specifically, moderate elevations of this function predicted good outcome at 3, 6, and 12 months. Very high elevations and minimal or no elevation predicted poor outcome at 3, 6, and 12 months. Possible reasons for these somewhat surprising results are discussed.

Evaluation of biofeedback in childhood encopresis

In order to evaluate the efficacy of biofeedback for childhood encopresis, 50 children with encopresis were prospectively studied and randomized to receive biofeedback (B) or mineral oil therapy (M). Specificity of biofeedback was also evaluated by comparing outcomes of both regimens in children with normal (n = 32) and abnormal (n = 18) defecation patterns. Using a single blinded design, there were no significant differences in clinical outcomes between the 24 children receiving B and the 26 children receiving M at 3, 6, and 12 months. However, at 12 months six of nine children with abnormal defecation patterns were in remission or markedly improved after receiving B, compared to only three of nine children receiving M. In contrast, children with normal patterns appeared to respond better to M than did those receiving B (71 vs. 40% at 12 months). Biofeedback appears to warrant further evaluation in children with encopresis and abnormal defecation patterns.

Age-related alterations in the stimulated release in vitro of catecholamines and luteinizing hormone-releasing hormone from the male rat hypothalamus

Using an in vitro perifusion system, the present study investigated the possibility that alterations in catecholamine and luteinizing hormone-releasing hormone (LHRH) secretion from the male rat mediobasal hypothalamus are present during the period of middle-age. The results indicate that, while tissue concentrations and baseline secretion of norepinephrine, dopamine and LHRH were similar between age groups, the patterns of dopamine and LHRH release in response to a series of depolarizing stimuli was different in the older animals. After all challenges, dopamine concentrations in the perifusate declined much more sharply for the middle-aged group, a finding that may be associated with a decrease with age in the pool of transmitter available for ready release. Also, tissue fragments from young adult rats were able to maintain the release of LHRH to a greater extent than tissue from the middle-aged animals, but only for the initial challenge period. The typical episodic pattern of LHRH release appeared to be disrupted in the older group following a second stimulus. It is possible that these age-related changes are early components of a disruption in the hypothalamic mechanisms governing gonadotropin secretion.

Information processing in rapid eye movement sleep. Possible neurophysiological, neuropsychological, and clinical correlates

Studies on cerebral hemispheric specialization suggest that the right and left hemispheres process information in different and sometimes conflicting ways. Rapid eye movement (REM) and non-REM sleep may reflect relatively greater activation or efficiency of the right and left hemispheres, respectively. Much of the mentation in wakefulness is dominated by the left hemisphere and its heavy language orientation. Modern theories of dreaming suggest that new solutions or adaptations to existing problems (i.e., new attitudes) may be enhanced by REM sleep and reflected in dreams. This report reviews experimental and clinical evidence to find neurophysiological, neuropsychological, and clinical support for the view that information is processed during REM sleep through increased activation, efficiency, and/or relative functional isolation of the right hemisphere.

Prevalence of behavior problems and mental health utilization among encopretic children: implications for behavioral pediatrics

The psychiatric literature traditionally has viewed encopretic children as having severe and characteristic behavior problems. Current psychiatric views as expressed in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III), and in the pediatric literature, however, tend to regard the behavior problems of encopretic children as being rather mild or secondary to the consequences of the encopresis itself. Using a behavioral checklist with empirically derived factors (the Child Behavior Checklist), 55 children presenting for medical treatment of their encopresis have been assessed. Numerous behavior problems are reported on parental ratings, but the overall severity of behavior problems in this group of children falls below that found in children with behavior problems who are referred for mental health services. Most children presenting for medical management of encopresis have not been seen or evaluated by mental health services. Encopresis is a disorder in which psychological evaluation and intervention by the pediatrician may be advisable.

Anorectal function and continence mechanisms in childhood encopresis

We compared anorectal sensory and motor functions, expulsion dynamics, and continence mechanisms in 50 children with encopresis and 21 healthy control children. When expulsion dynamics were studied, 43% of boys with encopresis inappropriately contracted the muscles near the anal canal compared with 10% of girls with encopresis (p greater than 0.05) and 10% of control children of both sexes (p less than 0.05). In contrast to previous studies we demonstrated no abnormalities of thresholds of conscious rectal sensation or internal anal sphincter relaxation. In addition, children with encopresis had no demonstrable abnormalities of rectosphincteric continence mechanisms or strength of external anal sphincter contraction. We conclude that a significant number of boys with encopresis have abnormal anorectal expulsion dynamics, which may contribute to chronic fecal retention and incontinence. Abnormalities of anorectal sensory and motor function and of rectosphincteric continence mechanisms do not seem to be important in the pathogenesis of childhood encopresis.

Neuropsychological capacity of Prader-Willi children: general and specific aspects of impairment

Although most Prader-Willi syndrome children perform in the mentally retarded ranges on standardized IQ tests, it is not known if their cognitive impairments are global in nature or if they exhibit a particular pattern of strengths and weaknesses in their psychological capacities. To examine this question, a cohort of children suffering from Prader-Willi syndrome was administered a battery of neuropsychological tests. The results indicated that, relative to other cognitive capacities assessed, particularly severe deficits were noted on tasks that involved information processing using the auditory modality. No differences in cognitive capacity were found between children with a number 15 chromosome defect and those with a normal karyotype configuration. Based on these initial findings, it appears that the clinical diagnosis of Prader-Willi syndrome is more important than a karyotype configuration in understanding these youngsters' manifest cognitive deficits.

Neuropsychological functioning in children with immunodeficiency disorders

A small group of children with various types of immunodeficiency disorders, examined on a battery of neuropsychological and intellectual tests, was found to be impaired on perceptual speed, visuospatial sequencing, and visual attention span capacities when compared to a control group of closest aged siblings and normal children matched for age, education, and IQ. The results suggest that cerebral dysfunction may be associated with immunodeficiency disorders in children, although these findings are tentative since other factors, such as the effects of chronic illness, could not be excluded in this small cohort of patients.