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Fatigue is a subjective overwhelming feeling of tiredness at rest, exhaustion with activity, lack of energy that impedes daily tasks, lack of endurance, or a loss of vigor. Individuals with end stage renal disease (ESRD) experience a high rate and severity of fatigue. Symptom management of fatigue in this population is critical, since fatigue has been linked with lower quality of life and higher mortality rates. In this article, we present a definition and overview of fatigue, a review of factors contributing to fatigue, and ways to manage fatigue in individuals with ESRD. Key Words: End stage renal disease, fatigue, symptom management., Fatigue is defined as a subjective overwhelming feeling of tiredness at rest, exhaustion with activity, lack of energy that impedes daily tasks, lack of endurance, or as loss of vigor [...]

Background: U.S. News & World Report's annual rankings of the top 50 American hospitals in 12 specialties are based on a combination of subjective and objective measures of quality. Although the rankings have been criticized for emphasizing the subjective reputation of hospitals too strongly, the role of reputation in determining the relative standings of the top 50 hospitals has not been quantified. Objective: To quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of U.S. News & World Report's rankings. Design: Cross-sectional study. Setting: The top 50 hospitals in each of 12 specialties. Measurements: Rankings based on the total U.S. News score and on a subjective reputation score. Results: On average, rankings based on reputation score alone agreed with U.S. News & World Report's overall rankings 100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals. Hospital reputation was minimally associated with objective quality measures (mean Spearman [[rho].sup.2] = 0.03). Limitation: The findings apply primarily to interpretations about the relative standings of the 50 top-ranked hospitals in each specialty and not necessarily to the hundreds of unranked hospitals. Conclusion: The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals. Primary Funding Source: None.

The Family Investigation of Nephropathy and Diabetes (FIND) was initiated to map genes underlying susceptibility to diabetic nephropathy. A total of 11 centers participated under a single collection protocol to recruit large numbers of diabetic sibling pairs concordant and discordant for diabetic nephropathy. We report the findings from the first-phase genetic analyses in 1,227 participants from 378 pedigrees of European-American, African-American, Mexican-American, and American Indian descent recruited from eight centers. Model-free linkage analyses, using a dichotomous definition for diabetic nephropathy in 397 sibling pairs, as well as the quantitative trait urinary albumin-to-creatinine ratio (ACR), were performed using the Haseman-Elston linkage test on 404 microsatellite markers. The strongest evidence of linkage to the diabetic nephropathy trait was on chromosomes 7q21.3, 10p15.3, 14q23.1, and 18q22.3. In ACR (883 diabetic sibling pairs), the strongest linkage signals were on chromosomes 2q14.1, 7q21.1, and 15q26.3. These results confirm regions of linkage to diabetic nephropathy on chromosomes 7q, 10p, and 18q from prior reports, making it important that genes underlying these peaks be evaluated for their contribution to nephropathy susceptibility. Large family collections consisting of multiple members with diabetes and advanced nephropathy are likely to accelerate the identification of genes causing diabetic nephropathy, a life-threatening complication of diabetes., Diabetic nephropathy (Online Mendelian Inheritance in Man [OMIM] no. 603933, available at http://www.ncbi.nlm.nih.gov/omim) is a common microvascular complication of type 1 and type 2 diabetes. Increasing prevalence of diabetic nephropathy [...]

The quality of hemodialysis care has been the focus of intense scrutiny, yet little is known about the job satisfaction of the nurses and technicians providing this care. We identified 240 nurses and technicians from 307 randomly selected American facilities and asked them about (a) specific domains of job satisfaction, (b) overall job satisfaction, and (c) self-reported patient care practices. Fewer than half of nurses and technicians were satisfied with their pay or their opportunities for advancement. Almost all subjects were satisfied with their personal delivery of patient care, their chance to do things for others, and their job security. About three-fourths of nurses and technicians expressed overall satisfaction with their jobs. Higher job satisfaction was associated with increased attention to patient psychosocial and educational needs. We urge local and national associations of nurses and technicians to collaborate with dialysis facilities, chains, and regulatory agencies to address specific aspects of job satisfaction., The quality of care provided to American hemodialysis patients has been the focus of intense scrutiny at local, regional, and national levels (McClellan et al., 1999). However, relatively little is [...]

Shortening and skipping hemodialysis treatments occur commonly and are associated with inadequate dialysis and increased mortality. These behaviors are also frequently equated with patient noncompliance. The prevalence and demographic correlates of shortening and skipping treatments have been studied extensively. However, less is known about the reasons for shortening and skipping treatments and whether patient characteristics correlate with specific reasons. Understanding the relationship between reasons and patient characteristics is essential for determining whether patient subgroups are at a disadvantage in achieving optimal dialysis and may help guide future interventions. Semistructured interviews were conducted with 168 selected patients who shortened or skipped treatments. A variety of reasons were responsible for shortening and skipping hemodialysis treatments. Content analysis of patient responses revealed five categories of reasons for shortening and skipping, including medical problems, technical problems, life tasks, transportation, and patient decisions. The most common reasons for shortening were medical problems (38%) and life tasks (24%), while the most common reasons for skipping were life tasks (33%) and transportation (22%). Furthermore, patient subgroups differed in the reasons for shortening and skipping. After multivariate adjustment for patient characteristics, technical problems were more common among women. Life tasks were more common among men, younger patients, and patients with hypertension. Transportation problems were more common among African Americans. Interventions to optimize hemodialysis treatment should identify and target patient-specific reasons for shortening and skipping and not assume noncompliance., Shortening and skipping hemodialysis treatments occurs commonly in the United States and is associated with inadequate dialysis and increased mortality (Leggat et al., 1998; Sehgal et al., 1998). Of all [...]

Malnutrition in hospitalized older patients is common and poses other health risks. Almost 60% of 369 examined older hospital patients were well nourished, but the remaining patients were moderately to severely malnourished. Nutritional deficits included weight loss and other physical symptoms. Extremely malnourished patients were most at risk to die within one year, recovered more slowly from their illness, and required more nursing home care than their well nourished counterparts.

We evaluate the suggestion that high-sensitivity C-reactive protein testing be used for risk assessment in the primary prevention of cardiovascular disease, using the criteria proposed by the Guide to Clinical Preventive Services developed by the US Preventive Services Task Force. We conclude that at present, none of the 3 major criteria--accuracy, reliability, and likelihood of beneficial intervention--are satisfied. Arch Intern Med. 2002;162:867-869

Background: Physicians are uniquely qualified to educate legislators about health care issues, but little is known about how physicians lobby members of Congress. Methods: From the staff of 84 randomly selected members of Congress (49 senators and 35 representatives), we interviewed the legislative assistants who work on health care legislation and meet with constituents and lobbyists on behalf of their senator or representative. We asked about (1) the frequency of meetings between legislative assistants and physicians, (2) the issues discussed, and (3) the perceived effectiveness of lobbying. Results: Senate and house legislative assistants met with an average of 10.0 and 4.0 physicians per month, respectively. This suggests that approximately 29 000 such meetings occur annually. The most common issues discussed were Medicare reimbursement (mentioned by 67 [81%] of 83 subjects), managed care reform (62 subjects [75%]), and funding for medical research (21 subjects [25%]). Other issues, such as access to care for the uninsured, tobacco control, abortion rights, and violence prevention, were rarely discussed. Most legislative assistants rated physicians as effective (37 [44%]) or somewhat effective (39 [46%]) as lobbyists. The most common suggestion for improving physician lobbying was to focus less on reimbursement and to address a broader range of health care issues. Conclusions: Physicians are frequent and effective lobbyists on reimbursement, managed care, and research issues. Policy makers appear receptive to increased physician input on a broader range of health care issues. Including these issues in lobbying efforts has the potential to shape health policy in a way that improves patient care and public health.