Despite the significant morbidity and mortality attributable to cardiovascular disease (CVD), risk stratification remains an important challenge in the chronic kidney disease(CKD) population. We examined the discriminative ability of non-invasive measures of atherosclerosis, including carotid intima-media thickness(cIMT), carotid plaque, coronary artery calcification(CAC) and ascending and descending thoracic aorta calcification(TCAC), and Framingham Risk Score (FRS) to predict self-reported prevalent CVD.
Methods and Results
Participants were enrolled in the cIMT ancillary study of the Chronic Renal Insufficiency Cohort(CRIC) Study and also had all of the above measures within an 18 month period. CVD was present in 21% of study participants. C-statistics were used to ascertain the discriminatory power of each measure of atherosclerosis. The study population (n=220) was 64% male; 51% black and 45% white. The proportion of individuals with estimated glomerular filtration rate ≥60, 45–59, 30–44, and <30ml/min/1.73m2 was 21%, 41%, 28%, and 11%, respectively. In multivariable analyses adjusting for demographic factors, we failed to find a difference between CAC, carotid plaque, and cIMT as predictors of self-reported prevalent CVD (c-statistic 0.70, 95% confidence interval [CI]: 0.62–0.78; c-statistic 0.68, 95% CI: 0.60–0.75, and c-statistic 0.64, CI: 0.56–0.72, respectively). CAC was statistically better than FRS. FRS was the weakest discriminator of self-reported prevalent CVD (c-statistic 0.58).
There was a significant burden of atherosclerosis among individuals with CKD, ascertained by several different imaging modalities. We were unable to find a difference in the ability of CAC, carotid plaque, and cIMT to predict self-reported prevalent CVD.
carotid intima media thickness; coronary artery calcification; kidney; plaque
We sought to determine whether mean platelet volume (MPV) is associated with the prevalence of peripheral artery disease (PAD).
Platelets play a pivotal role in the pathogenesis of atherosclerosis and PAD. MPV, a measure of platelet size available in every blood count, is increasingly recognized as an important marker of platelet activity.
We analyzed data from 6354 participants aged 40 years and older from the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. PAD was defined as an ankle brachial index ≤0.90 in either leg. Odds ratios and 95% confidence intervals were estimated by logistic regression.
The prevalence of PAD in the cohort was 5.7%. MPV was significantly associated with PAD prevalence (tertile 1 – 4.4%, tertile 2 – 6.1%, tertile 3 – 7.0%, P for trend = 0.003). After adjustment for age, sex, and race, the odds ratio of PAD comparing the highest tertile to the lowest tertile was 1.57 (95% confidence interval 1.15–2.13). After further adjustment for smoking status, hypertension, hypercholesterolemia, diabetes, glomerular filtration rate, body mass index, and platelet count the corresponding odds ratio was 1.58 (95% confidence interval 1.14–2.19). The addition of triglycerides, hemoglobin A1c, and C-reactive protein did not affect the results. The significant association between MPV and PAD was unchanged when MPV was used as a continuous variable.
Mean platelet volume is independently associated with PAD. These findings support the hypothesis that platelet size is an independent predictor of increased risk for PAD.
Mean platelet volume; Platelets; Peripheral artery disease; Epidemiology
Few predictive indexes for long-term mortality have been developed for community-dwelling elderly populations. Parsimonious predictive indexes are important decision-making tools for clinicians, policy makers, and epidemiologists.
To develop 1-, 5-, and 10-year mortality predictive indexes for nationally representative community-dwelling elderly people.
The Second Longitudinal Study of Aging (LSOA II).
Nationally representative civilian community-dwelling persons at least 70 years old. We randomly selected 60% of the sample for prediction development and used the remaining 40% for validation.
Sociodemographics, impairments, and medical diagnoses were collected from the LSOA II baseline interviews. Instrumental activities of daily living (IADLs) stages were derived to measure functional status. All-cause mortality was obtained from the LSOA II Linked Mortality Public-use File.
The analyses included 7,373 sample persons with complete data, among which mortality rates were 3.7%, 23.3%, and 49.8% for 1, 5, and 10 years, respectively. Four, eight, and ten predictors were identified for 1-, 5-, and 10-year mortality, respectively, in multiple logistic regression models to create three predictive indexes. Age, sex, coronary artery disease, and IADL stages were the most essential predictors for all three indexes. C-statistics of the three indexes were 0.72, 0.74, and 0.75 in the development cohort and 0.72, 0.72, and 0.74 in the validation cohort for 1-, 5-, and 10-year mortality, respectively. Five risk groups were defined based on the scores.
The 1-, 5-, and 10-year mortality indexes include parsimonious predictor sets maximizing ease of mortality prediction in community settings. Thus, they may provide valuable information for prognosis of elderly patients and guide the comparison of alternative interventions. Including IADL stage as a predictor yields simplified mortality prediction when detailed disease information is not available.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2027-3) contains supplementary material, which is available to authorized users.
mortality; prediction; score system; community; instrumental activities of daily living
Glomerular filtration rate (GFR) is considered the best measure of kidney function, but repeated assessment is not feasible in most research studies.
Cross-sectional study of 1,433 participants from the Chronic Renal Insufficiency Cohort (CRIC) Study (i.e., the GFR subcohort) to derive an internal GFR estimating equation using a split sample approach.
Setting & Participants
Adults from 7 US metropolitan areas with mild to moderate chronic kidney disease; 48% had diabetes and 37% were black.
CRIC GFR estimating equation
Reference Test or Outcome
Urinary 125I-iothalamate clearance testing (measured GFR)
Laboratory measures including serum creatinine and cystatin C, and anthropometrics
In the validation dataset, the model that included serum creatinine, serum cystatin C, age, gender, and race was the most parsimonious and similarly predictive of mGFR compared to a model additionally including bioelectrical impedance analysis phase angle, CRIC clinical center, and 24-hour urinary creatinine excretion. Specifically, the root mean square errors for the separate model were 0.207 vs. 0.202, respectively. The performance of the CRIC GFR estimating equation was most accurate among the subgroups of younger participants, men, non-blacks, non-Hispanics, those without diabetes, those with body mass index <30 kg/m2, those with higher 24-hour urine creatinine excretion, those with lower levels of high-sensitivity C-reactive protein, and those with higher mGFR.
Urinary clearance of 125I-iothalamate is an imperfect measure of true GFR; cystatin C is not standardized to certified reference material; lack of external validation; small sample sizes limit analyses of subgroup-specific predictors.
The CRIC GFR estimating equation predicts measured GFR accurately in the CRIC cohort using serum creatinine and cystatin C, age, gender, and race. Its performance was best among younger and healthier participants.
glomerular filtration rate (GFR); kidney function; GFR estimation
Retinal vascular and anatomic abnormalities caused by diabetes, hypertension, and other conditions can be observed directly in the ocular fundus and may reflect severity of chronic renal insufficiency. The purpose of this study was to investigate the association between retinopathy and chronic kidney disease (CKD).
In this observational, cross-sectional study, 2605 participants of the Chronic Renal Insufficiency Cohort (CRIC) study, a multi-center study of CKD, were offered participation. Non-mydriatic fundus photographs of the disc and macula in both eyes were obtained in 1936 of these subjects.
Photographs were reviewed in a masked fashion at a central photograph reading center using standard protocols. Presence and severity of retinopathy (diabetic, hypertensive or other) and vessel diameter caliber were assessed by trained graders and a retinal specialist using protocols developed for large epidemiologic studies. Kidney function measurements and information on traditional and non-traditional risk factors for decreased kidney function were obtained from the CRIC study.
Greater severity of retinopathy was associated with lower estimated glomerular filtration rate (eGFR) after adjustment for traditional and non-traditional risk factors. Presence of vascular abnormalities usually associated with hypertension was also associated with lower eGFR. We found no strong direct relationship between eGFR and average arteriolar or venular calibers.
Our findings show a strong association between severity of retinopathy and its features and level of kidney function after adjustment for traditional and non-traditional risk factors for CKD, suggesting that retinovascular pathology reflects renal disease.
Retinopathy; Retinal Vascular Diameter; Chronic Kidney Disease
To determine the patient-, treatment-, and facility-level factors that are associated with home discharge among male veterans with lower extremity amputation who received inpatient rehabilitation after surgery.
A retrospective observational study.
Veterans Affairs Medical Centers.
This study included 1480 male veterans.
Generalized estimating equation models were used to model the likelihood of home discharge to account for within-facility clustering. We reported odds ratios (ORs) and 95% confidence intervals (95% CIs).
Main Outcome Measurement
Discharged to home.
There were a total of 1163 (78.6%) veterans who were discharged home after the surgical hospitalization, compared with other locations. Patients who were married were more likely to be discharged home compared with patients who were not married (OR = 1.51, 95% CI = 1.14–1.99, P < .01). Compared with being transferred from another hospital or extended care, patients who were admitted from home were far more likely to be discharged home (OR = 8.43, 95% CI = 5.48–12.96, P < .0001). Patients with evidence of local significant infection were less likely to be discharged home (OR = 0.57, 95% CI = 0.39–0.83, P < .01), as were patients with evidence of congestive heart failure (OR = 0.62, 95% CI = 0.45–0.85, P < .01) or depression (OR = 0.63, 95% CI = 0.40–0.98, P = .04). Veterans with greater discharge motor Functional Independence Measure scores were more likely to be discharged home (OR = 1.23, 95% CI = 1.16–1.31 per 10-point increase in discharge Functional Independence Measure motor score, P < .0001). Conversely, patients undergoing procedures for ongoing active cardiac pathology were less likely to be discharged home (OR = 0.55, 95% CI = 0.37–0.81, P < .01).
This study showed a strong association between the sociological factors of marital status and living location before hospitalization and home discharge. The significance of discharge functional status highlights the importance of addressing the expected care burden once patients are discharged home.
Patients with chronic kidney disease (CKD) experience co-morbid illneses including cardiovascular disease (CVD) and retinopathy. The purpose of this study was to assess the association between retinopathy and self reported CVD in a subgroup of the participants of the Chronic Renal Insufficiency Cohort (CRIC) study. In this observational, ancillary investigation, 2605 CRIC participants were invited to participate in this study, and non-mydriatic fundus photographs in both eyes were obtained in 1936 subjects. Photographs were reviewed in a masked fashion at a central photograph reading center. Presence and severity of retinopathy (diabetic, hypertensive or other) and vessel diameter caliber were assessed using standard protocols by trained graders masked to information about study participants. History of self-reported cardiovascular disease was obtained using a medical history questionnaire. Kidney function measurements, traditional and non-traditional risk factors for CVD were obtained from the CRIC study. Greater severity of retinopathy was associated with higher prevalence of any cardiovascular disease and this association persisted after adjustment for traditional risk factors for CVD. Presence of vascular abnormalities usually associated with hypertension was also associated with increased prevalence of CVD. We found a direct relationship between CVD prevalence and mean venular caliber. In conclusion, presence of retinopathy was associated with CVD, suggesting that retinovascular pathology may be indicative of macrovascular disease even after adjustment for renal dysfunction and traditional CVD risk factors. This would make assessment of retinal morphology a valuable tool in chronic kidney disease studies of CVD outcomes.
Retinopathy; chronic kidney disease; cardiovascular disease
Depressive symptoms are correlated with poor health outcomes in adults with chronic kidney disease (CKD). The prevalence, severity, and treatment of depressive symptoms and potential risk factors, including level of kidney function, in diverse populations with CKD have not been well studied.
Settings and Participants
Participants at enrollment into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies. CRIC enrolled Hispanics and non-Hispanics at seven centers from 2003-2007, and H-CRIC enrolled Hispanics at the University of Illinois from 2005-2008.
Depressive symptoms measured by Beck Depression Inventory (BDI)
Demographic and clinical factors
Elevated depressive symptoms (BDI >= 11) and antidepressant medication use
Among 3853 participants, 28.5% had evidence of elevated depressive symptoms and 18.2% were using antidepressant medications; 30.8% of persons with elevated depressive symptoms were using antidepressants. The prevalence of elevated depressive symptoms varied by level of kidney function: 25.2% among participants with eGFR ≥ 60 ml/min/1.73m2, and 35.1% of those with eGFR < 30 ml/min/1.73m2. Lower eGFR (OR per 10 ml/min/1.73m2 decrease, 1.09; 95% CI, 1.03-1.16), Hispanic ethnicity (OR, 1.65; 95% CI, 1.12-2.45), and non-Hispanic black race (OR, 1.43; 95% CI, 1.17-1.74) were each associated with increased odds of elevated depressive symptoms after controlling for other factors. In regression analyses incorporating BDI score, while female sex was associated with a greater odds of antidepressant use, Hispanic ethnicity, non-Hispanic black race, and higher levels of urine albumin were associated with decreased odds of antidepressant use (p<0.05 for each).
Absence of clinical diagnosis of depression and use of non-pharmacologic treatments
Although elevated depressive symptoms were common in individuals with CKD, use of antidepressant medications is low. African Americans, Hispanics, and individuals with more advanced CKD had higher odds of elevated depressive symptoms and lower odds of antidepressant medication use.
Patients with chronic kidney disease (CKD) have an increased risk of developing peripheral arterial disease (PAD). We examined the cross-sectional association between novel risk factors and prevalent PAD among patients with CKD. A total of 3,758 patients with an estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m2 who participated in the chronic renal insufficiency cohort (CRIC) study were included in the current analysis. PAD was defined as an ankle-brachial index <0.9 or a history of arm or leg revascularization. After adjustment for age, sex, race, cigarette smoking, physical activity, history of hypertension and diabetes, pulse pressure, high-density lipoprotein cholesterol, eGFR, and CRIC clinical sites, several novel risk factors were significantly associated with PAD. For example, odds ratios (95% confidence intervals) for a one standard deviation higher level of risk factors were 1.18 (1.08–1.29) for log-transformed high sensitivity-C reactive protein, 1.18 (1.08–1.29) for white blood cell count, 1.15 (1.05–1.25) for fibrinogen, 1.13 (1.03–1.24) for uric acid, 1.14 (1.02–1.26) for hemoglobin A1c, 1.11 (1.00–1.23) for log-transformed homeostasis model assessment-insulin resistance, and 1.35 (1.18–1.55) for cystatin C. In conclusion, these data indicate that inflammation, prothrombotic state, oxidative stress, insulin resistance, and cystatin C were associated with an increased prevalence of PAD in patients with CKD. Further studies are warranted to examine the causal effect of these risk factors on PAD in CKD patients.
peripheral arterial disease; novel risk factors; chronic kidney disease
Evaluate the reliability and validity of the Kidney Disease Quality of Life Short Form 36 (KDQOL-36™) in Hispanics with mild-to-moderate chronic kidney disease (CKD).
Chronic Renal Insufficiency Cohort Study
420 Hispanic (150 English- and 270 Spanish-speakers), and 409 non-Hispanic White individuals, matched by age (mean 57 years), sex (60% male), kidney function (mean estimated glomerular filtration rate 36ml/min/1.73m2), and diabetes (70%).
To measure construct validity, we selected instruments, comorbidities, and laboratory tests related to at least one KDQOL-36™ subscale. Reliability was determined by calculating Cronbach’s alpha.
Reliability of each KDQOL-36™ subscale [SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS), Symptoms/Problems, Burden of Kidney Disease and Effects of Kidney Disease] was very good (Cronbach’s alpha >0.8). Construct validity was supported by expected negative correlation between MCS scores and the Beck Depression Inventory in all three subgroups (r= −0.56 to −0.61, P<.0001). There was inverse correlation between the Symptoms/Problems subscale and the Patient Symptom Form (r= −0.70 to −0.77, P<.0001). We also found significant, positive correlation between the PCS score and a physical activity survey (r= +0.29 to +0.38, P≤.003); and between the PCS and MCS scores and the Kansas City Questionnaire (r= +0.31 to +0.64, P<.0001). Reliability and validity were similar across all racial/ethnic groups analyzed separately.
Our findings support the use of the KDQOL-36™ as a measure of HRQOL in this cohort of US Hispanics with CKD.
Validation; Quality of Life; Hispanics
The association between platelet activity, diabetes, and glucometabolic control is uncertain. We aim to investigate mean platelet volume (MPV), a marker of platelet size and platelet activity, with the prevalence of diabetes, metabolic syndrome, and degree of glycemic control.
RESEARCH DESIGN AND METHODS
This is a retrospective analysis of 13,021 participants in the National Health and Nutrition Examination Survey from 1999 to 2004. Prevalence of diabetes was defined as nonfasting glucose >200 mg/dL, fasting glucose ≥126 mg/dL, or treatment with hypoglycemic agents. Presence of metabolic syndrome was determined by the National Cholesterol Education Program Adult Treatment Panel III definition. Odds ratios and 95% CIs were estimated by logistic regression.
MPV was significantly higher in subjects with diabetes (8.20 vs. 8.06 femtoliter [fL], P < 0.01) but not in subjects with metabolic syndrome (8.09 vs. 8.07 fL, P = 0.24). For the metabolic syndrome components, MPV was significantly higher in abdominal obesity (P = 0.03) and low HDL (P = 0.04), and not different in high blood pressure (P = 0.07), abnormal glucose metabolism (P = 0.71), or hypertriglyceridemia (P = 0.46). There was a significant correlation between MPV and glucose (P < 0.0001) and between MPV and hemoglobin A1c (P < 0.0001) in subjects with diabetes. These correlations were no longer significant in those without diabetes. The adjusted odds of diabetes rose with increasing MPV levels and were most pronounced in subjects with MPV levels exceeding the 90th percentile (≥9.31 fL). The association between MPV and diabetes was most apparent in those with the poorest glucose control.
Mean platelet volume is strongly and independently associated with the presence and severity of diabetes.
This study’s objective was to determine how treatment-, environmental-, and facility-level characteristics contribute to postdischarge mortality prediction. The study included 4,153 Veterans who underwent lower-limb amputation in Department of Veterans Affairs facilities during fiscal years 2003 and 2004. Veterans were followed 1 yr postamputation. A Cox regression identified characteristics associated with mortality risk after hospital discharge following amputation. Older age, higher amputation level, and more comorbidities increased mortality likelihood. Patients who had inpatient procedures for pulmonary and renal problems had higher hazards of postdischarge death than those who did not (hazard ratio [HR] = 2.10, 95% confidence interval [CI] = 1.16–3.77, and HR = 2.22, 95% CI = 1.80–2.74, respectively). Patients who had central nervous system procedures had higher hazards of death early postdischarge (HR = 2.23, 95% CI = 1.60–3.11) at 0 d, but this association became insignificant by 180 d. Patients in a surgical intensive care unit (ICU), medical ICU, or medical bed section at the time of discharge were more likely to die than patients on a surgical bed section. Patients hospitalized in the Midwest were less likely to die early after discharge than patients in the Mountain Pacific region, but this regional effect became insignificant by 90 d. Adding treatment-, environmental-, and facility-level characteristics contributed additional information to a mortality risk model.
administrative data; amputation; comorbidity; elderly; integrated; lower limb; mortality; outcome assessment; rehabilitation; Veteran
Limitation in the activities of daily living (ADLs) is strongly prognostic for mortality. Current ADL assessments based on numbers of limitations (counts) obscure the particular activities limited, thus lacking clinical interpretability.
To examine the independent association of 5 stages of ADL with mortality after accounting for known diagnostic and sociodemographic risk factors.
For five stages (ADL 0 to IV), describing both the severity and pattern of ADLs limited, we estimated unadjusted life expectancies and adjusted associations with mortality using a Cox proportional hazards regression model.
Included were 9,447 persons 70 years of age and older from the second Longitudinal Study of Aging.
1-, 5-, and 10-year survival and time to death.
For those with no ADL limitations, the median life expectancy was 10.6 years compared to 6.5, 5.1, 3.8, and 1.6 years for those at ADL I, II, III, and IV, respectively. The sociodemographic and diagnostic-adjusted hazard of death at 1 year was 5-fold greater at stage IV compared to stage 0 (hazard ratio=5.6; 95% confidence interval, 3.8–8.3). The associations of ADL stage with mortality declined over time, but remained statistically significant at 5 and 10 years.
ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.
Activities of Daily Living; Staging; Mortality; Risk factors
Little is known regarding chronic kidney disease (CKD) in Hispanics. We compared baseline characteristics of Hispanic participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies with non-Hispanic CRIC participants.
Setting and Participants
Participants were aged 21–74 years with CKD using age-based glomerular filtration rate (eGFR) at enrollment into the CRIC/H-CRIC Studies. H-CRIC included Hispanics recruited at the University of Illinois from 2005–2008 while CRIC included Hispanics and non-Hispanics recruited at seven clinical centers from 2003–2007.
Blood pressure, angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) use, CKD-associated complications
Demographic characteristics, laboratory data, blood pressure, and medications were assessed using standard techniques and protocols
Among H-CRIC/ CRIC participants, 497 were Hispanic, 1650 non-Hispanic Black, and 1638 non-Hispanic White. Low income and educational attainment were nearly twice as prevalent in Hispanics compared with non-Hispanics (p<0.01). Hispanics had self-reported diabetes (67%) more frequently than non-Hispanic Blacks (51%) and Whites (40%) (p<0.01). Blood pressure > 130/80 mmHg was more common in Hispanics (62%) compared with Blacks (57%) and Whites (35%) (p<0.05), and abnormalities in hematologic, metabolic, and bone metabolism parameters were more prevalent in Hispanics (p<0.05), even after stratifying by entry eGFR. Hispanics had the lowest receipt of ACE inhibitor/ARB among high-risk subgroups, including participants with diabetes, proteinuria, and blood pressure > 130/80 mmHg. Mean eGFR (ml/min/m2) was lower in Hispanics (39.6) than in Blacks (43.7) and Whites (46.2), while median proteinuria was higher in Hispanics (0.72 g/d) than in Blacks (0.24 g/d) and Whites (0.12 g/d) (p<0.01).
Generalizability; observed associations limited by residual bias and confounding
Hispanics with CKD in CRIC/H-CRIC Studies are disproportionately burdened with lower socioeconomic status, more frequent diabetes mellitus, less ACE inhibitor/ARB use, worse blood pressure control, and more severe CKD and associated complications than their non-Hispanic counterparts.
chronic kidney disease; Hispanics; epidemiology
To determine patient, treatment, or facility characteristics that influence decisions to initiate a rehabilitation assessment before transtibial or transfemoral amputation within the Veterans Affairs (VA) health care system.
Retrospective database study.
VA medical centers.
A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004.
Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date.
Evidence was found that 343 of 4226 veterans (8.12%) with lower extremity amputations received preoperative rehabilitation assessments. Veterans receiving preoperative rehabilitation were more likely to be older, admitted from home, or transferred from another hospital. Patients who underwent surgical amputation at smaller-sized hospitals or in the South Central or Mountain Pacific regions were more likely to receive preoperative rehabilitation compared with patients in mid-sized hospitals or in the Northeast, Southeast, or Midwest regions. Patients with evidence of paralysis, patients treated in facilities with programs accredited by the Commission on Accreditation of Rehabilitation Facilities (P < .01), and patients in the second data wave were less likely to receive preoperative rehabilitation. After accounting for patient-, treatment-, and facility-level structural characteristics, we found that older patients were more likely to receive preoperative rehabilitation services (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01–1.02). Patients with a contributing amputation etiology of a previous amputation complication were more likely to receive preoperative consultation rehabilitation services (OR 1.50, 95% CI 1.02–2.19) compared with patients who did not have this etiology. Compared with patients treated in the Southeast region of the United States, those treated in the South Central region (OR 2.52, 95% CI 1.82–3.48) or Mountain Pacific region (OR 1.62, 95% CI 1.11–2.37) were more likely to receive preoperative consultation rehabilitation services. Patients with evidence of paralysis were less likely to receive preoperative rehabilitative services compared with patients who did not have this condition (OR 0.29, 95% CI 0.09–0.93), and patients treated in mid-sized hospitals also were less likely to receive preoperative rehabilitative services compared with patients treated in smaller-sized facilities (OR 0.38, 95% CI 0.27–0.53). Veterans in the second data year were less likely to receive services compared with patients in the first year (OR 0.74, 95% CI 0.58–0.94).
Rehabilitation assessment before lower extremity amputation surgery is a rare occurrence in the VA health care system. Practice patterns appear to be driven by location and not by patient characteristics.
Previous studies have demonstrated relationships between sleep and both obesity and diabetes. Additionally, exercise may improve sleep and daytime function, in addition to weight and metabolic function. The present study extends these findings by examining how general sleep-related complaints are associated with body mass index (BMI), diabetes diagnosis, and exercise in a large, nationally representative sample.
Subject and methods
Participants were respondents to the Behavioral Risk Factor Surveillance System (BRFSS). Sleep complaint (SC) was measured with “Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?” Daytime complaint (DC) was measured with “Over the last 2 weeks, how many days have you felt tired or had little energy?” Responses were dichotomized, with ≥6 days indicating complaint. Covariates included age, race/ethnicity, income, and education.
Being overweight was associated with DC in women only. Obesity was significantly associated with SC and DC in women, and DC in men. Diabetes was associated with SC and DC in both genders. Any exercise in the past 30 days did not attenuate any BMI or diabetes relationships, but was independently associated with a decrease in SC and DC in both men and women.
These results suggest that for both men and women diabetes is a significant predictor of sleep and daytime complaints, and there is a relationship between obesity and sleep and complaints for women to a greater extent than men. Finally, exercise was associated with much fewer sleep and daytime complaints in both genders.
Sleep; Sleep disturbance; Obesity; Diabetes; Exercise
To explore the influence of physical home and social environments and disability patterns on nursing home (NH) use.
Longitudinal cohort study. Self- or proxy-reported perception of home environmental barriers accessibility, 5 stages expressing the severity and pattern of activities of daily living (ADLs) limitations, and other characteristics at baseline were applied to predict NH use within 2 years or prior to death through logistic regression.
Population-based, community-dwelling individuals (N=7836; ≥70y) from the Second Longitudinal Study of Aging interviewed in 1994 with 2-year follow-up that was prospectively collected.
Main Outcome Measure
NH use within 2 years.
Perceptions of home environmental barriers and living alone were both associated with approximately 40% increased odds of NH use after adjustment for other factors. Compared with those with no limitations at ADL stage 0, the odds of NH use peaked for those with severe limitations at ADL stage III (odds ratio [OR]=3.12; 95% confidence interval [CI], 2.20 – 4.41), then declined sharply for those with total limitations at ADL stage IV (OR=.96; 95% CI, .33–2.81). Sensitivity analyses for missing NH use showed similar results.
Accessibility of home environment, living circumstance, and ADL stage represent potentially modifiable targets for rehabilitation interventions for decreasing NH use in the aging U.S. population.
Activities of daily living; Nursing homes; Rehabilitation
To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services following lower extremity amputation within Veterans Affairs (VA) system.
A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services.
All VA Medical Centers.
4,165 veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004.
Main Outcome Measures
Receipt of outpatient rehabilitation services up to one year post-discharge.
Sixty-five percent of veterans with lower extremity amputation received outpatient services. Older veterans, patients admitted for surgical amputation from extended care rather than transferred from another hospital, and those with trans-femoral and/or bilateral rather than unilateral trans-tibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous disorders, active cardiac pathology, serious nutritional compromise, and severe renal disease during the surgical hospitalization less often initiated outpatient care. Patients who received inpatient consultative rehabilitation compared to inpatient specialized rehabilitation; and who were treated in the Northeast compared to the Southeast region less often initiated outpatient care. Finally those discharged to home or other locations rather than extended care had an initial increased likelihood of receiving outpatient service, but by 180 days post-discharge those discharged to extended care were more likely to initiate outpatient services.
Both clinical characteristics and types of rehabilitation services received appear to influence receipt of outpatient rehabilitation services. Geographic location also impacted receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation.
lower extremity amputation; outpatient rehabilitation; veterans
Henry-Sánchez JT, Kurichi JE, Xie D, Pan Q, Stineman MG: Do elderly people at more severe activity of daily living limitation stages fall more? Am J Phys Med Rehabil 2012;91:601–610.
The aim of this study was to explore how activity of daily living (ADL) stages and the perception of unmet needs for home accessibility features associate with a history of falling.
Participants were from a nationally representative sample from the Second Longitudinal Survey of Aging conducted in 1994. The sample included 9250 community-dwelling persons 70 yrs or older. The associations of ADL stage and perception of unmet needs for home accessibility features with a history of falling within the past year (none, once, or multiple times) were explored after accounting for sociodemographic characteristics and comorbidities using a multinomial logistic regression model.
The adjusted relative risk of falling more than once peaked at 4.30 (95% confidence interval, 3.29–5.61) for persons with severe limitation (ADL-III) compared those with no limitation (ADL-0) then declined for those at complete limitation (ADL-IV). The adjusted relative risks of falling once and multiple times were 1.42 (95% confidence interval, 1.07–1.87) and 1.85 (95% confidence interval, 1.44–2.36), respectively, for those lacking home accessibility features.
Risk of falling appeared greatest for those whose homes lacked accessibility features and peaked at intermediate ADL limitation stages, presumably at a point when people have significant disabilities but sufficient function to remain partially active.
Accidental Falls; Aged; Risk Assessment; Activities of Daily Living
Metabolic syndrome may increase the risk for incident cardiovascular disease (CVD) and all-cause mortality in the general population. It is unclear whether, and to what degree, metabolic syndrome is associated with CVD in chronic kidney disease (CKD). We determined metabolic syndrome prevalence among individuals with a broad spectrum of kidney dysfunction, examining the role of the individual elements of metabolic syndrome and their relationship to prevalent CVD.
We evaluated four models to compare metabolic syndrome or its components to predict prevalent CVD using prevalence ratios in the Chronic Renal Insufficiency Cohort (CRIC) Study.
Among 3,939 CKD participants, the prevalence of metabolic syndrome was 65% and there was a significant association with prevalent CVD. Metabolic syndrome was more common in diabetics (87.5%) compared with non-diabetics (44.3%). Hypertension was the most prevalent component, and increased triglycerides the least prevalent. Using the bayesian information criterion, we found that the factors defining metabolic syndrome, considered as a single interval-scaled variable, was the best of four models of metabolic syndrome, both for CKD participants overall and for diabetics and non-diabetics separately.
The predictive value of this model for future CVD outcomes will subsequently be validated in longitudinal analyses.
Cardiovascular disease; Chronic kidney disease; Chronic Renal Insufficiency Cohort (CRIC) Study; Metabolic syndrome
To better understand linkages between impairment and activity limitation among groups of elderly community-living persons.
US population-based complex survey with weights used to make accurate population prevalence estimates from the 1994 NHIS-D. Included were 2,429 persons 70 years of age or older with one or more ADL or IADL-only activity limitations. Limitations were addressed according to the impairment(s) perceived to be causing them.
Musculoskeletal impairments accounted for over 1/3 of all perceived causes. The odds of having any ADL limitations for persons whose limitations were attributed to musculoskeletal impairments and to brain or behavioral impairments were 2.12 times (95% CI 1.63–2.76) and 3.00 times (95% CI 2.23–4.03) the odds for the reference group of cardiopulmonary and hematology impairment
While musculoskeletal impairments were the most common cause of activity limitation, impairments associated with brain or behavioral disturbance were perceived as most disabling.
Activities of Daily Living; Brain disease; Aging; Classification; ICF
To determine what patient- and facility-level characteristics drive late specialized rehabilitation among veterans who already received immediate postoperative services.
Data were obtained from 8 administrative databases for 2,453 patients who underwent lower extremity amputation in Veterans Affairs Medical Centers in 2002-2004. A Cox proportional hazards model was used to determine the hazards ratios and 95% confidence intervals of the factors associated with days to readmission for late services after discharge from the surgical hospitalization.
There were 2,304 patients who received only immediate postoperative services, while 152 also received late specialized rehabilitation. After adjustment, veterans who were less disabled physically, residing in the South Central compared to the Southeast region, and had their surgeries in CARF accredited facilities were all more likely to receive late services. The hazards ratios for type of immediate postoperative rehabilitation were not constant over time. At hospital discharge, there was no difference in receipt, however, after 3 months, those who received early specialized rehabilitation were significantly less likely to receive late services.
The factors associated with late specialized rehabilitation were due mainly to facility-level characteristics and care process variables. Knowledge of these factors may help with decision-making policies regarding CARF accredited units.
Rehabilitation; Inpatient; Lower Extremity; Veteran
Background. Secondary hyperparathyroidism is a common complication of chronic kidney disease (CKD) that is associated with bone disease, cardiovascular disease and death. Pathophysiological factors that maintain secondary hyperparathyroidism in advanced CKD are well-known, but early mechanisms of the disease that can be targeted for its primary prevention are poorly understood. Diuretics are widely used to control volume status and blood pressure in CKD patients but are also known to have important effects on renal calcium handling, which we hypothesized could alter the risk of secondary hyperparathyroidism.
Methods. We examined the relationship of diuretic treatment with urinary calcium excretion, parathyroid hormone (PTH) levels and prevalence of secondary hyperparathyroidism (PTH ≥ 65 pg/mL) in a cross-sectional study of 3616 CKD patients in the Chronic Renal Insufficiency Cohort.
Results. Compared with no diuretics, treatment with loop diuretics was independently associated with higher adjusted urinary calcium (55.0 versus 39.6 mg/day; P < 0.001), higher adjusted PTH [67.9, 95% confidence interval (CI) 65.2–70.7 pg/mL, versus 52.8, 95% CI 51.1–54.6 pg/mL, P < 0.001] and greater odds of secondary hyperparathyroidism (odds ratio 2.1; 95% CI 1.7–2.6). Thiazide monotherapy was associated with lower calciuria (25.5 versus 39.6 mg/day; P < 0.001) but only modestly lower PTH levels (50.0, 95% CI 47.8–52.3, versus 520.8, 95% CI 51.1–54.6 pg/mL, P = 0.04) compared with no diuretics. However, coadministration of thiazide and loop diuretics was associated with blunted urinary calcium (30.3 versus 55.0 mg/day; P <0.001) and odds of hyperparathyroidism (odds ratio 1.3 versus 2.1; P for interaction = 0.05) compared with loop diuretics alone.
Conclusions. Loop diuretic use was associated with greater calciuria, PTH levels and odds of secondary hyperparathyroidism compared to no treatment. These associations were attenuated in patients who were coadministered thiazides. Diuretic choice is a potentially modifiable determinant of secondary hyperparathyroidism in CKD.
calciuria; chronic kidney disease; diuretics; parathyroid hormone
This study aimed to describe the conceptual foundation and development of an activity limitation and participation restriction staging system for community-dwelling people 70 yrs or older according to the severity and types of self-care (activities of daily living [ADLs]) and domestic life (instrumental ADLs (IADLs)) limitations experienced.
Data from the second Longitudinal Study of Aging (N = 9447) were used to develop IADL stages through the analyses of self- and proxy-reported difficulties in performing IADLs. An analysis of activity limitation profiles identified hierarchical thresholds of difficulty that defined each stage. IADL stages are combined with ADL stages to profile status for independent living.
IADL stages define five ordered thresholds of increasing activity limitations and a “not relevant” stage for those who normally have someone else do those activities. Approximately 42% of the population experience IADL limitations. To achieve a stage, a person must meet or exceed stage-specific thresholds of retained functioning defined for each activity. Combined ADL and IADL stages de-fine 29 patterns of activity limitations expressing the individual’s potential for participating in life situations pertinent to self-care and independent community life.
ADL and IADL stages can serve to distinguish between groups of people according to both severity and the types of limitations experienced during home or outpatient assessments, in population surveillance, and in research.
Independent Living; Aging; Daily Living Activities; ICF
To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.
Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).
Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).
ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI) = 2.4–4.4) to 41.9 (95% CI = 19.6–89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR = 17.8, 95% CI = 13.0–24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.
ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.
activities of daily living; staging; chronic disease; environment; biopsycho-ecological framework