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This cohort study compares outcomes including hospital length of stay and 30-day rates of complications after nonelective subtotal cholecystectomy vs total cholecystectomy among patients with cholecystitis.

Strengthening mental health nurses' (MHNs) resilience may help mitigate the negative effects of the emotional labour (EL) of their work. There is no prior evidence on MHNs' experiences of resilience in the context of EL. This interpretive qualitative study sought to explore how MHNs build and maintain their resilience in the face of high levels of EL. Semi-structured interviews were conducted with 11 MHNs. Reflexive thematic analysis was used to analyse the data. Four main themes were constructed. The first three; Being attuned to self and others, Having a positive mindset grounded in purpose, and Maintaining psychological equilibrium through proactive self-care, describe how MHNs build and maintain their resilience. The fourth theme, Running on emotionally empty, describes what impedes MHNs' resilience. MHNs engaged in internal self-regulatory processes to manage their mental and emotional state. They maintained intra- and inter-personal boundaries and proactively used self-care strategies to maintain their well-being. Through this, they were able to replenish and sustain the energy required to maintain a state of equilibrium between themselves, their interpersonal practice, and their working environment, and to positively adapt to EL. However, lack of organizational support and high workplace demands can negatively impact MHNs' equilibrium and adaptive ability. There is a need for organizations to proactively work to reduce workplace stressors, and support MHNs' professional well-being and practice. Education and support strategies focused on strengthening MHNs' resilience, well-being, and mental health practice capabilities, including the provision of clinical supervision, and clear role expectations within MHNs' scope of practice are recommended.

The importance of muscle wasting as a predictor of mortality in the hemodialysis population is not clear. Lack of association of muscle mass with survival in some studies could be related to reliance on single measures or to incorporation of excess extracellular water (ECW) into estimates of muscle mass. We examined changes in body composition over a 2-year period and the association of body composition with survival.We analyzed data from 325 adults receiving hemodialysis in the Bay Area. We estimated ECW, intracellular water (ICW), and fat mass by whole-body bioimpedance spectroscopy (BIS) at 0, 12, and 24 months from enrollment. We used linear mixed modeling to examine changes in body mass index and BIS-derived estimates of body composition and Cox modeling with BIS-derived estimates as time-varying independent variables to examine associations between body composition and survival in multivariable analyses.Body mass index declined over time. Considering individual components of body composition, ICW declined (-0.09 kg/mICW declined over 2 years in this cohort, whereas fat mass and ECW remained relatively stable. Higher ICW was associated with better survival, but higher fat mass was not. Higher ECW was associated with worse survival. These results suggest that muscle mass may predict survival among patients on hemodialysis.

Recent recognitions of longstanding societal effects of structural and overt acts of racism have led to calls for the elimination of race, a social construct, from medical algorithms. This accelerated a growing concern with the use of race in kidney function estimating equations. A task force sponsored by the two leading nephrology societies in the United States has reassessed the inclusion of race in glomerular filtration rate (GFR) estimation and recently put forth recommendations. New race-free equations have been developed and guides for widespread implementation have been provided. We herein review the journey of kidney function estimating equations, race in GFR estimating equations, new race-free equations and the path forward in caring for chronic kidney disease. We urge upon all primary care providers to employ concerted focus on early detection and identification of kidney dysfunction as well as risk factors including social determinants of health to prevent progression.

OBJECTIVES: Health-related quality of life (HRQoL) measures capture the patient’s experience of the burden of chronic disease and are strongly associated with adverse health-related outcomes across multiple populations. The SF-36 score is the most widely used HRQoL measure among patients with end-stage renal disease (ESRD). Current understanding of determinants of the physical component summary (PCS) and the mental component summary (MCS) and their association with objectively measured physical performance and activity is limited. DESIGN: Cross-sectional study. SETTING AND SUBJECTS: As an index of HRQoL, we prospectively examined the association of SF-36 and its component scores with physical function among 155 incident dialysis patients from the Hemodialysis Center. We investigated associations of HRQoL with the physical performance-based components of the frailty using multivariate linear and logistic regression after adjustment for confounders. PREDICTOR: HRQoL score. MAIN OUTCOME: Impaired physical performance was defined as having either slow usual gait speed or weak handgrip strength based on standardized and validated criteria derived from a large cohort study of older adults. RESULTS: The patients had a mean age of 65 ± 11 years, and 52.3% were male. After adjusting confounders, lower PCS was independently associated with decreased physical performance and reduced physical activity, but MCS was not associated. Among the PCS subscales, only physical functioning 10 (PF-10) was consistently associated with outcomes, and every 1 point increase in PF-10 score was associated with 4% lower odds of impaired physical performance (95%CI: 2 to 7%; P=0.01) after adjustment. CONCLUSIONS: SF-36, especially PF-10, is a valid surrogate that discriminates low physical performance and physical inactivity in the absence of formal physical function testing in patients on hemodialysis. The routine implementation of the PF-10 in clinical care has important clinical implications for medical management and therapeutic decision-making in patients undergoing hemodialysis.

Objective Irisin is a hormone released by muscle in response to exercise that acts on white adipose cells to stimulate browning of adipose tissue. We aimed to examine irisin correlates and consequences of irisin in patients receiving hemodialysis. Design and Methods A prospective cohort study was conducted using data from 749 prevalent patients receiving hemodialysis. Multivariable linear regression and multivariable generalized estimating equations were used to determine correlates of baseline and change in serum irisin concentration. Proportional hazards (Cox) regression was used to assess the association between serum irisin concentration and time to death. Results Age and body mass index were inversely associated with baseline and change in serum irisin concentration. Lower muscle mass as estimated by serum creatinine concentration was associated with lower irisin concentration (−1.38% per mg/dL (95% confidence interval [CI]: −2.45, −0.21) and with a 0.72% decrease in irisin concentration (95% CI: −1.48, −0.04) from baseline to 12 months. Each 50% higher serum interleukin-6 (IL-6) concentration was associated with 1.52% higher serum irisin concentration (95% CI: 0.38, 2.66) at baseline and an increase of 1.04% in irisin concentration over 1 year (95% CI: 0.47, 1.61). Irisin concentration at baseline was associated with higher hazard of death (hazards ratio: 1.45, 95% CI: 1.05 2.00); an increase in irisin concentration over 1 year was associated with a higher hazard of death (hazards ratio: 1.34, 95% CI: 1.01, 1.79). In formal mediation analysis, serum IL-6 was a mediator in the association between serum irisin and mortality. Conclusions Lower serum creatinine (reflecting lower muscle mass) and higher serum IL-6 were associated with higher serum irisin concentrations. Higher serum irisin concentrations were associated with higher mortality, which may be mediated by inflammation.

For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.

The aim of the study was to assess the effect of the summer thermal environment on physiological responses, behaviour, milk production and its composition on grazing dairy cows in a temperate climate region, according to the stage of lactation. Twenty-nine Holstein Friesian multiparous cows were randomly selected and divided into two groups, according to the days in milk, as mid-lactation (99 to 170 d in milk, n = 15) and late lactation (225 to 311 d in milk, n = 14). The comprehensive climate index (CCI) was used to classify the hour of each day as thermoneutral or heat stress, considering a threshold value of CCI of 20°C. Data were collected for 16 d (summer 2017) and analysed as a completely randomized 2 × 2 factorial arrangement with repeated measurements over time. Vaginal temperature increased with CCI ≥ 20°C. Respiration rates were dependent on the thermal condition, regardless of days in milk. There was an interaction between the time of day and the CCI category for activity and rumination. Grazing activity decreased by 17.6% but lying down, standing, and shaded animals increased by 1.6, 9.8, and 6.3% respectively when CCI ≥ 20°C. Over 80% of cows presented a panting score ≥1. However, milk production and composition (fat, protein, and lactose concentrations as well as somatic cell count) were not affected by the thermal condition, although there was a numerical (non-significant) decrease in afternoon milk protein concentration on days with CCI ≥ 20°C, while urea in milk increased. In conclusion, thermal condition challenged grazing dairy cows' behaviour and physiology independent of the stage of lactation but had little or no effect on milk production.

Background and ObjectiveChronic kidney disease (CKD) is associated with loss of muscle quality leading to mobility limitation and decreased independence. Identifying predictors of gait speed decline may help target rehabilitative therapies to those at highest risk of mobility impairment.Design, setting and participants, and measurementsThe current prospective cohort study recruited ambulatory patients with stage 1-4 CKD (eGFR 15-89 ml/min/1.73m2) from nephrology clinics. Predictors included demographic and clinical variables including GFR estimated using serum cystatin C. Outcomes were average change in gait speed (m/s) per year and inclusion in the top tertile of gait speed decline over 3 years. Linear mixed models and relative risk regression were used to estimate associations with annual gait speed changes and fastest tertile of decline.ResultsAmong 213 participants, 81% were male, 22% were black and 43% had diabetes. Mean age was 57±13 years, median follow-up 3.15 years, mean baseline eGFRcysc 47.9±21ml/min/1.73 m2, and median baseline gait speed 0.95m/s [IQR 0.81, 1.10]. Lower baseline eGFRcysc was associated with more rapid loss of gait speed (−0.029 m/s/year [95% CI -0.042, -0.015] per 30 ml/min/1.73 m2 lower eGFR; pp=.008) after adjustment.Prevalent cardiovascular disease and African American race were associated with a 45% greater (IRR 1.45; 95% CI 1.04, 2.01, p=.03) and 58% greater rate of rapid gait speed decline (IRR 1.58; 95% CI 1.09, 2.29, p=.02), respectively.ConclusionsAmong ambulatory, disability-free patients with CKD, lower eGFRcysc and diabetes status were associated with faster gait speed decline. Lower eGFRcysc, cardiovascular disease, and African American race were associated with rapid gait speed decline.

Background A randomized trial of a pedometer-based intervention with weekly activity goals led to increased walking among dialysis patients. However, the association of participant-expressed motivations and barriers to participation and performance in such an intervention has not been determined. Methods Thirty dialysis patients were randomized to a 12-week pedometer-based intervention with weekly step goals. Participants were asked about motivations and barriers to the increasing activity via weekly semi-scripted telephone interviews. We examined the association of these motivations and barriers with achieving weekly goals, reaching overall targets and increasing steps through multivariable linear and logistic regression analyses adjusted for age, sex, body mass index, dialysis modality and baseline steps. Results The most common motivations were desire to maintain/improve functional ability (30%) and activity (30%). The most common barriers were health-related (33%). Motivation to maintain/improve functional ability was associated with achieving weekly goals 17.9% more often [95% confidence interval (CI) 1.7–34.2] and with a greater increase in steps (1524 steps; 95% CI 61–2989) than those lacking this motivation. Experiencing a health-related barrier was not associated with the decreased achievement of weekly goals but was associated with lower odds of reaching overall targets (odds ratio = 0.06; 95% CI 0.01–0.53) and a smaller increase in steps (−1640 steps, 95% CI −3244 to −36). No patients who reported weather/environmental barriers or safety concerns reached overall targets. Conclusions Participants who express a desire to maintain/improve functional ability may be particularly suited for activity interventions. Health-related setbacks should be met with revised goals. Reporting environmental or safety concerns may merit lowering overall targets.

Racial and social unrest witnessed during 2020 ignited a national conversation about the appropriateness of the use of race in health care algorithms and in the estimation of kidney function in particular. The growing concerns over the use of race in kidney function-estimating equations prompted the National Kidney Foundation (NKF) and American Society of Nephrology to launch an effort for change by establishing a task force on reassessing the use of race in diagnosing kidney disease. After nearly a year examining the evidence and obtaining testimony from experts and stakeholders, the task force recommended the immediate implementation of the 2020 Chronic Kidney Disease-Epidemiology creatinine equation refit without race in all US laboratories; increased routine use of cystatin C for confirmation of estimated glomerular filtration rate in clinical decision-making and a call for research on glomerular filtration rate estimation with new endogenous filtration markers and on addressing disparities in health and health care. The NKF and American Society of Nephrology strongly encouraged rapid adoption of these new recommendations. Leadership efforts of the NKF have begun to lay the foundation for national implementation through laboratory engagement, clinician awareness, and patient education.

Background In response to a national call for reevaluation of the use of race in clinical algorithms, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess inclusion of race in the estimation of glomerular filtration rate (eGFR) in the United States and its implications for diagnosis and management of patients with, or at risk for, kidney diseases. Process & Deliberations The Task Force organized its activities over 10 months in phases to: 1) clarify the problem and evidence regarding eGFR equations in the United States (described previously in an Interim Report), and in this Final Report 2) evaluate approaches to address use of race in GFR estimation and 3) provide recommendations. We identified 26 approaches for the estimation of GFR that did or did not consider race and narrowed our focus by consensus to five of those approaches. We holistically evaluated each approach considering six attributes: assay availability and standardization; implementation; population diversity in equation development; performance compared to measured GFR; consequences to clinical care, population tracking and research; and patient centeredness. To arrive at a unifying approach to estimate GFR, we integrated information and evidence from many sources in assessing strengths and weaknesses in attributes for each approach, recognizing the number of Black and non-Black adults affected. Recommendations #1) For U.S. adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the U.S. because it does not include race in the calculation and reporting, includes diversity in its development, is immediately available to all labs in the U.S., and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals. #2) We recommend national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults who are at risk for or have chronic kidney disease, because combining filtration markers (creatinine and cystatin C) is more accurate and would support better clinical decisions that either one marker alone. If ongoing evidence supports acceptable performance, the CKD-EPI eGFR-cystatin C (eGFRcys) and eGFR creatinine-cystatin C (eGFRcr-cys_R) refit without the race variables should be adopted to provide another first line test in addition to confirmatory testing. #3) Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded. An investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR measurement and estimation without the inclusion of race, and that promote health equity and do not generate disparate care. Implementation This unified approach, without specification of race, should be adopted across the U.S. High-priority and multi-stakeholder efforts should implement this solution.

Background Protein-energy wasting, muscle mass (MM) loss and sarcopenia are highly prevalent and associated with poor outcome in haemodialysis (HD) patients. Monitoring of MM and/or muscle metabolism in HD patients is of paramount importance for timely detection of muscle loss and to intervene adequately. In this study we assessed the reliability and reproducibility of a simplified creatinine index (SCI) as a surrogate marker of MM and explored its predictive value on outcome. Method We included all in-centre HD patients from 16 European countries with at least one SCI. The baseline period was defined as 30 days before and after the first multifrequency bioimpedance spectroscopy measurement; the subsequent 7 years constituted the follow-up. SCI was calculated by the Canaud equation. Multivariate Cox proportional hazards models were applied to assess the association of SCI with all-cause mortality. Using backward analysis, we explored the trends of SCI before death. Bland–Altman analysis was performed to analyse the agreement between estimated and measured MM. Results We included 23 495 HD patients; 3662 were incident. Females and older patients have lower baseline SCI. Higher SCI was associated with a lower risk of mortality [hazard ratio 0.81 (95% confidence interval 0.79–0.82)]. SCI decline accelerated ∼5–7 months before death. Lean tissue index (LTI) estimated by SCI was correlated with measured LTI in both sexes (males: R2 = 0.94; females: R2 = 0.92; both P

Introduction: A randomized, controlled trial of a pedometer-based walking intervention with weekly activity goals led to increased walking among dialysis patients. We examined whether impairment per cognitive function screening is associated with adherence and performance in the intervention. Methods: Thirty dialysis patients were randomly assigned to a 3-month pedometer-based intervention with weekly goals. Participants were administered the Telephone Interview of Cognitive Status (TICS), a test of global mental status. We examined the association of levels of impairment on the TICS (≥33: unimpaired, 26–32: ambiguous impairment, 21–25: mild cognitive impairment [MCI]) with adherence, achieving weekly goals, and increasing steps, physical performance (Short Physical Performance Battery, SPPB), and self-reported physical function (PF) through multivariable linear mixed-model and logistic regression analyses adjusted for age, sex, BMI, dialysis modality, baseline steps, baseline SPPB, and stroke status. Results: One-third of participants were unimpaired, and 13% had MCI. Participants with worse results on cognitive function screening missed more calls and completed fewer weekly goals than participants with better results. During the intervention, a worse result on cognitive function screening was associated with smaller increases in steps compared to those without impairment: (ambiguous: −620 [95% CI −174, −1,415], MCI: −1,653 [95% CI −120, −3,187]); less improvement in SPPB (ambiguous: −0.22 points [95% CI −0.08, −0.44], MCI: −0.45 [95% CI −0.13, −0.77]); and less improvement in PF (ambiguous: −4.0 points [95% CI −12.2, 4.1], MCI: −14.0 [95% CI −24.9, −3.1]). During the postintervention period, a worse result on cognitive function screening was associated with smaller increases in SPPB (ambiguous: −0.54 [95% CI −1.27, 0.19], MCI: −0.97 [95% CI −0.37, −1.58]) and PF (ambiguous: −3.3 [95% CI −6.5, −0.04], MCI: −10.5 [95% CI −18.7, −2.3]). Discussion/Conclusion: Participants with worse results on cognitive function screening had worse adherence and derived less benefit from this pedometer-based intervention. Future exercise interventions should be developed incorporating methods to address cognitive impairment, for example, by including caregivers when planning such interventions.

Mental health nurses (MHNs) frequently face emotional adversity and stressors at work that can negatively impact their psychological well-being and result in mental distress. This can affect their capacity for therapeutic work, professional relationships, and overall work performance. In the context of work, resilience is a dynamic process of positive adaptation to adversity that can lead to psychological well-being and increased work performance. There is limited knowledge, however, on MHNs' psychological well-being and resilience from an Australian perspective. This study aimed to investigate the levels of, and relationships between, psychological well-being, mental distress, and workplace resilience in Australian MHNs. A cross-sectional online survey using Ryff's Scales of Psychological Well-being (PWS) 18, Depression, Anxiety and Stress (DASS) 21, and Resilience at Work measures was completed by registered nurses (n = 482) working in a mental health setting or role. Mean scores were 85.38 for psychological well-being and 70.27 for workplace resilience, with more than half reporting levels above the mean. However, some participants scored in the severe to extremely severe categories for depression (7.8%), anxiety (8.7%) or stress (7.3%). Psychological well-being had strong positive and negative associations, respectively, with workplace resilience (r = 0.571, P < 0.01) and depression (r = -0.563, P < 0.01). Having a postgraduate specialist qualification was positively associated with psychological well-being. Postgraduate speciality education may be a key protective factor that can increase MHNs' psychological well-being. Strengthening workplace resilience is an important strategy for organizations to implement to support MHNs' psychological well-being and reduce the risk of mental distress.

Emotional labour is a form of adversity faced by mental health nurses in the context of their workplace interactions. Frequent exposure to emotional adversity can negatively impact mental health nurses' biopsychosocial well-being, workplace relationships, and performance. Workplace resilience is a dynamic interactive process within and between the person and their environment that promotes positive adaptation to adverse events and restores well-being. Workplace resilience could be a protective process that helps mental health nurses positively adapt to workplace emotional adversity. This study aimed to investigate Australian mental health nurses' workplace resilience and emotional labour and explore the relationship between them. A national cross-sectional online survey comprising the Resilience at Work and Emotional Labour scales was completed by registered nurses (n = 482) working in a mental health role or setting across Australia. There was a strong negative relationship between resilience and the emotional labour strategy of surface acting. A positive association between resilience, frequency of emotional labour, and clinical supervision was also found. These findings point to a potential link between mental health nurses' skills of cognitive reframing, and emotional and behavioural regulation needed to effectively manage their emotions and remain therapeutic in interpersonal interactions. Clinical supervision may be a key strategy in supporting mental health nurses' resilience. Further investigation of workplace individuals' internal and external resources, and organizational resources, supports, and strategies that can promote and strengthen mental health nurses' well-being is needed.

Background Despite the high prevalence of frailty among patients receiving hemodialysis, few preventable or treatable contributing causes have been identified. Hypogonadism is also common in this population and low serum testosterone concentrations share several clinical phenotypes with frailty. We hypothesized that low serum testosterone concentrations would be associated with frailty and several of its individual components. Methods We used data from 440 men from A Cohort Study To Investigate the Value of Exercise in ESRD/Analysis Designed to Investigate the Paradox of Obesity and Survival in ESRD, a longitudinal study that recruited participants from 14 dialysis centers in Atlanta, GA and the San Francisco, CA Bay Area from 2009 to 2011. We assessed frailty using the Fried Frailty Phenotype. We examined the association between free testosterone (as a continuous and dichotomous variable) and frailty, individual frailty components, sarcopenia, lower extremity function and muscle mass estimation by creatinine and body impedance spectroscopy over 12 months using generalized estimating equations. Results The mean age was 56.1 ± 14.2 years and 27% were white. A 50% lower concentration of free testosterone was associated with 1.40-fold higher odds of being frail [95% confidence interval (CI) 1.05–1.53] and 1.40-fold higher odds of becoming frail over 12 months (95% CI 1.07–1.73). This association was mainly due to an association with two components of frailty: grip strength and gait speed. In addition, 50% lower free testosterone concentration was associated with a 1.55-fold higher odds of having sarcopenia (95% CI 1.09–2.02) and 1.72-fold higher odds for developing sarcopenia (95% CI 1.13–2.33) as well as with lower muscle mass and a decrease in muscle mass over 12 months as estimated by serum creatinine and by bioelectrical impedance spectroscopy. Conclusion Serum free testosterone concentration was associated with frailty, physical function, sarcopenia and muscle mass as well as with changes in these outcomes over 12 months. Testosterone replacement may be a feasible therapeutic target toward prevention of frailty, although clinical trials are needed to test this possibility.

BACKGROUND AND OBJECTIVES: Low eGFR is known to be associated with frailty, but the association between the longitudinal decline of eGFR and incident frailty in older persons remains to be determined. The objective of this study was to investigate whether a fast decline on eGFR would be associated with incident frailty. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Community dwellers, aged ≥70, were included in this secondary analysis of the 5-year Multidomain Alzheimer Preventive Trial (MAPT). eGFR was calculated using CKD–Epidemiology Collaboration equation at baseline and at 6, 12, and 24 months. The lowest quartile of eGFR slope (−4.1 ml/min per 1.73 m(2) per yr) defined a fast decline. The frailty phenotype (unintentional weight loss, exhaustion, low physical activity, slow gait, low handgrip strength assessed with a 0–5 score, where higher is worse; a score ≥3 defines frailty) was assessed at baseline, 6, 12, 24, 36, 48, and 60 months. Cox models were used to test the association between fast eGFR decline and incident frailty. RESULTS: A total of 833 participants were frail neither at baseline nor at 2 years and had appropriate follow-up data. Median (IQR) baseline eGFR was 73 (61–84) ml/min per 1.73 m(2). Frailty occurred in 95 (11%) participants between 24 and 60 months. Among them, 31/207 (15%) had fast eGFR decline between baseline and 24 months, and 64/626 (10%) did not. In a Cox model adjusted for demographic variables, cardiovascular comorbidity, C-reactive protein, and baseline eGFR, a fast eGFR decline was associated with incident frailty (HR 1.67, 95% CI 1.03 to 2.71). Sensitivity analyses provided consistent findings. CONCLUSIONS: In community-dwelling older adults with relatively preserved baseline eGFR, a fast eGFR decline is associated with incident frailty.

The relative importance of sarcopenia and its individual components as independent predictors of mortality in the dialysis population have not been determined. We estimated whole-body muscle mass using pre-dialysis bioimpedance spectroscopy measurements in 645 ACTIVE/ADIPOSE enrolled prevalent hemodialysis patients from San Francisco and Atlanta. Low muscle mass was defined as two standard deviations below sex-specific means for young adults from NHANES and indexed to height2, body weight, body surface area, or body mass index. We evaluated the association of sarcopenia (low muscle mass) by four indexing methods, weak handgrip strength, and slow gait speed with mortality. Seventy-eight deaths were observed during a mean follow-up of 1.9 years. Sarcopenia was not significantly associated with mortality after adjusting for covariates. No muscle mass criteria were associated with death, regardless of indexing metrics. In contrast, having weak grip strength or slow walking speed was associated with mortality in the adjusted model. Only gait slowness significantly improved the predictive accuracy for death with an increase in C-statistic from 0.63 to 0.68. However, both gait slowness and hand grip weakness significantly improved the net reclassification index compared to models without performance measures (50.5% for slowness and 33.7% for weakness), whereas models with muscle size did not. Neither sarcopenia nor low muscle mass by itself was a better predictor of mortality than functional limitation alone in patients receiving hemodialysis. Thus, physical performance measures, including slow gait speed and weak hand grip strength, were associated with mortality even after adjustment for muscle size and other confounders.

This present study is a report of an interview study exploring personal views on participating in group clinical supervision among mental health nursing staff members who do not participate in supervision. There is a paucity of empirical research on resistance to supervision, which has traditionally been theorized as a supervisee's maladaptive coping with anxiety in the supervision process. The aim of the present study was to examine resistance to group clinical supervision by interviewing nurses who did not participate in supervision. In 2015, we conducted semistructured interviews with 24 Danish mental health nursing staff members who had been observed not to participate in supervision in two periods of 3 months. Interviews were audio-recorded and subjected to discourse analysis. We constructed two discursive positions taken by the informants: (i) 'forced non-participation', where an informant was in favour of supervision, but presented practical reasons for not participating; and (ii) 'deliberate rejection', where an informant intentionally chose to not to participate in supervision. Furthermore, we described two typical themes drawn upon by informants in their positioning: 'difficulties related to participating in supervision' and 'limited need for and benefits from supervision'. The findings indicated that group clinical supervision extended a space for group discussion that generated or accentuated anxiety because of already-existing conflicts and a fundamental lack of trust between group members. Many informants perceived group clinical supervision as an unacceptable intrusion, which could indicate a need for developing more acceptable types of post-registration clinical education and reflective practice for this group.

Background There is no consensus on how best to define low muscle mass in patients with end-stage renal disease. Use of muscle mass normalized to height-squared has been suggested by geriatric societies but may underestimate sarcopenia, particularly in the setting of excess adiposity. We compared four definitions of low muscle mass in a prevalent hemodialysis cohort. Methods ACTIVE/ADIPOSE enrolled prevalent patients receiving hemodialysis from the San Francisco and Atlanta areas from June 2009 to August 2011. Whole-body muscle mass was estimated using bioelectrical impedance spectroscopy, performed before a midweek dialysis session (n = 645; age 56.7 ± 14.5 years, 41% women). We defined low muscle mass as muscle mass of 2SD or more below sex-specific bioelectrical impedance spectroscopy-derived means for young adults (18–49 years) from National Health and Nutrition Examination Survey and indexed to height2, body weight (percentage), body surface area (BSA) by the DuBois formula, or Quetelet's body mass index (BMI). We compared prevalence of low muscle mass among the four methods and assessed their correlation with strength and physical performance. Results The prevalence of low muscle mass ranged from 8 to 32%. Muscle mass indexed to height2 classified the smallest percentage of patients as having low muscle mass, particularly among women, whereas indexing by BSA classified the largest percentage. Low muscle mass/height2 was present almost exclusively among normal or underweight patients, whereas indexing to body weight and BMI classified more overweight and obese patients as having low muscle mass. Handgrip strength was lower among those with low muscle mass by all methods except height2. Handgrip strength was directly and modestly correlated with muscle mass normalized by percentage of body weight, BSA, and BMI (ρ = 0.43, 0.56, and, 0.64, respectively) and less so with muscle/height2 (ρ = 0.31, P

Compromised physical health and raised levels of morbidity and mortality are experienced by young people (16-24 years) with mental illness, and are compounded by psychotropic medication. How this group conceives and experiences physical health is not well understood. We investigated the meanings, beliefs, and endeavours of young people that impact their physical health understandings and behaviours. The present study formed the qualitative phase of a sequential mixed-methods study, and incorporated semistructured interviews with 12 hospitalized young people. Qualitative content analysis was used to analyse data. Participants held a holistic ideal of physical health that they did not meet. Weight change, poor sleep, and limited exercise adversely impacted their lives and self-image. Sedentary behaviour, reduced energy, and limited health literacy compromised effective management of physical health. Young people needed structure and support to assist them in addressing their physical health needs when amotivation overwhelmed their internal resources. Nurses are well placed to help young people increase their competency for health management. Individualized information and methods to promote good physical health are required for this group in jeopardy from physical morbidity and mortality.

© 2018 National Kidney Foundation, Inc. Objective: Fibroblast growth factor 23 (FGF-23) may be involved in signaling between bone and adipose tissue in dialysis patients, but its role is uncertain. We sought to examine the association between FGF-23 and adiposity and whether this association is mediated in part by leptin. Design/Setting: We performed univariate and multivariate linear regression analyses using data from 611 participants in a cohort of prevalent hemodialysis patients recruited from dialysis centers in Atlanta, GA and San Francisco, CA from 2009 to 2011. We also investigated the role of leptin in these relationships. Subjects: Participants were aged ≥18 years, English or Spanish speaking, and receiving hemodialysis for at least 3 months. Main Outcome Measures: Outcome measures of adiposity included body mass index, waist circumference, and body fat measured by bioelectrical impedance spectroscopy. Results: Mean age was 56 ± 14 years, 39.8% were female, and median serum FGF-23 was 807 pg/mL. In fully adjusted models, FGF-23 was inversely associated with body mass index (−0.24 kg/m2per 50% higher FGF-23, 95% confidence interval [CI]: −0.38 to −0.10), waist circumference (−0.44 cm per 50% higher FGF-23, 95% CI: −0.79 to −0.08), and percent body fat (−0.58% per 50% higher FGF-23, 95% CI: −0.79 to −0.37). Leptin was inversely associated with FGF-23. Addition of leptin to body composition models attenuated the associations between FGF-23 and measures of adiposity, but FGF-23 remained significantly associated with percent body fat (−0.17% per 50% higher FGF-23, 95% CI: −0.32 to −0.02). Conclusion: We found a negative association between FGF-23 and adiposity that appears to be mediated in part by leptin. As adipose tissue provides a “protective energy depot” for patients with chronic illness, a decrease in adipose tissue may be one mechanism in which higher FGF-23 levels may contribute to increased mortality in dialysis patients.

Background: Understanding how components of frailty change over time and how they can be modeled as time-dependent predictors of mortality could lead to better risk prediction in the dialysis population. Methods: We measured frailty at baseline, 12 months, and 24 months among 727 patients receiving hemodialysis in Northern California and Atlanta. We examined the likelihood of meeting frailty components (weight loss, exhaustion, low physical activity, weak grip strength, and slow gait speed) as a function of time in logistic regression analysis and association of frailty components with mortality in time-updated multivariable Cox models. Results: Physical activity and gait speed declined, exhaustion and grip strength did not change, and the odds of meeting the weight loss criterion declined with time. All five components were associated with higher mortality in multivariable analyses, but gait speed was the strongest individual predictor. All frailty components except physical inactivity were independently associated with mortality when all five components were included in the same model. The number of frailty components met was associated with mortality in a gradient that ranged from a hazard ratio of 2.73 for one component to 10.07 for five components met; the model including all five components was the best model based on Akaike information criterion. Conclusions: Measurement of all frailty components was necessary for optimal mortality prediction, and the number of components met was strongly associated with mortality in this cohort.

Ischemia-reperfusion injury (IRI) occurs when blood returns to tissues following a period of ischemia. Reintroduction of blood flow results in the production of free radicals and reactive oxygen species that damage cells. Skeletal muscle IRI is commonly seen in orthopedic trauma patients. Experimental studies in other organ systems have elucidated the importance of extracellular and intracellular matrix metalloproteinase-2 (MMP-2) isoforms in regulating tissue damage in the setting of oxidant stress resulting from IRI. Although the extracellular full-length isoform of MMP-2 (FL-MMP-2) has been previously studied in the setting of skeletal muscle IRI, studies investigating the role of the N-terminal truncated isoform (NTT-MMP-2) in this setting are lacking. In this study, we first demonstrated significant increases in FL- and NTT-MMP-2 gene expression in C2C12 myoblast cells responding to re-oxygenation following hypoxia in vitro. We then evaluated the expression of FL- and NTT-MMP-2 in modulating skeletal muscle IRI using a previously validated murine model. NTT-MMP-2, but not FL-MMP-2 expression was significantly increased in skeletal muscle following IRI. Moreover, the expression of toll-like receptors (TLRs) -2 and -4, IL-6, OAS-1A, and CXCL1 was also significantly up-regulated following IRI. Treatment with the potent anti-oxidant pyrrolidine dithiocarbamate (PDTC) significantly suppressed NTT-MMP-2, but not FL-MMP-2 expression and improved muscle viability following IRI. This data suggests that NTT-MMP-2, but not FL-MMP-2, is the major isoform of MMP-2 involved in skeletal muscle IRI. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

Background Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are available about downstream events resulting from or following these hospitalizations. Study Design Retrospective cohort study using the US Renal Data System. Setting & Participants Medicare beneficiaries initiating in-center hemodialysis therapy in 2005 to 2008. Factors Demographics, dual Medicare/Medicaid eligibility, body mass index, comorbid conditions, initial vascular access type, nephrology care prior to dialysis therapy initiation, residence in a care facility, tobacco use, biochemical measures, and type of infection. Outcomes 30-day hospital readmission or death following first infection-related hospitalization. Results 60,270 Medicare beneficiaries had at least one hospitalization for infection. Of those who survived the initial hospitalization, 15,113 (27%) were readmitted and survived the 30 days following hospital discharge, 1,624 (3%) were readmitted to the hospital and then died within 30 days of discharge, and 2,425 (4%) died without hospital readmission. Complications related to dialysis access, sepsis, and heart failure accounted for 12%, 9%, and 7% of hospital readmissions, respectively. Factors associated with higher odds of 30-day readmission or death without readmission included non-Hispanic ethnicity, lower serum albumin level, inability to ambulate or transfer, limited nephrology care prior to dialysis therapy, and specific types of infection. In comparison, older age, select comorbid conditions, and institutionalization had stronger associations with death without readmission than with readmission. Limitations Findings limited to Medicare beneficiaries receiving in-center hemodialysis. Conclusions Hospitalizations for infection among patients receiving in-center hemodialysis are associated with exceptionally high rates of 30-day hospital readmission and death without readmission.

Summary Objective To investigate the state of knowledge on emotional intelligence (EI) education in pre-registration nursing programmes. Design Integrative literature review. Data sources CINAHL, Medline, Scopus, ERIC, and Web of Knowledge electronic databases were searched for abstracts published in English between 1992–2014. Review methods Data extraction and constant comparative analysis of 17 articles. Results Three categories were identified: Constructs of emotional intelligence; emotional intelligence curricula components; and strategies for emotional intelligence education. Conclusions A wide range of emotional intelligence constructs were found, with a predominance of trait-based constructs. A variety of strategies to enhance students' emotional intelligence skills were identified, but limited curricula components and frameworks reported in the literature. An ability-based model for curricula and learning and teaching approaches is recommended.

Physical activity questionnaires usually focus on moderate to vigorous activities and may not accurately capture physical activity or variation in levels of activity among extremely inactive groups like dialysis patients.Cross-sectional study.Three dialysis facilities in the San Francisco Bay Area.Sixty-eight prevalent hemodialysis patients.We administered a new physical activity questionnaire designed to capture activity in the lower end of the range, the Low Physical Activity Questionnaire (LoPAQ).Outcome measures were correlation with a validated physical activity questionnaire, the Minnesota Leisure Time Activity (LTA) questionnaire and with self-reported physical function (physical function score of the SF-36) and physical performance (gait speed, chair stand, balance, and short physical performance battery). We also determined whether patients who were frail or reported limitations in activities of daily living were less active on the LoPAQ.Sixty-eight participants (mean age 59 ± 14 years, 59% men) completed the study. Patients were inactive according to the LoPAQ, with a median (interquartile range) of 517 (204-1190) kcal/week of physical activity. Although activity from the LTA was lower than on the LoPAQ (411 [61-902] kcal/week), the difference was not statistically significant (P = .20), and results from the 2 instruments were strongly correlated (rho = 0.62, P .001). In addition, higher physical activity measured by the LoPAQ was correlated with better self-reported functioning (rho = 0.64, P .001), better performance on gait speed (rho = 0.32, P = .02), balance (rho = 0.45, P .001), and chair rising (rho = -0.32, P = .03) tests and with higher short physical performance battery total score (rho = 0.51, P .001). Frail patients and patients with activities of daily living limitations were less active than those who were not frail or limited.The LoPAQ performed similarly to the Minnesota LTA questionnaire in our cohort despite being shorter and easier to administer.

Background: Although frailty has been linked to higher risk of falls and fracture in the general population, only few studies have examined the extent to which frailty is associated with these outcomes among patients with end-stage renal disease, who are at particularly high risk for these events. Methods: A total of 1,646 patients who were beginning maintenance hemodialysis in 297 dialysis units throughout the United States from September 2005 to June 2007 were enrolled in the Comprehensive Dialysis Study, and 1,053 Medicare beneficiaries were included in this study. Self-reported frailty was defined by the patients endorsing 2 or more of the following: poor physical functioning, exhaustion or low physical activity. Falls and fractures requiring medical attention were identified through Medicare claims data. We examined the association between frailty and the time to first fall or fracture using the Fine-Gray modification of Cox proportional hazards regression, adjusted for demographics, Quételet's body mass index, diabetes mellitus, heart failure and atherosclerosis. Results: Seventy-seven percent of patients were frail by self-report. The median length of follow-up was 2.5 (1.0-3.9) years. Crude rates of first medically urgent falls or fractures were 66 and 126 per 1,000 person-years in non-frail and self-reported frail participants, respectively. After accounting for demographic factors, comorbidities and the competing risk of death, self-reported frailty was associated with a higher risk of falls or fractures requiring medical attention (hazards ratio 1.60, 95% CI 1.16-2.20). Conclusion: Participants reporting frailty experienced nearly twice the risk of medically urgent falls or fractures compared to those who did not report frailty.

Background In hemodialysis (HD) patients, higher lipid levels are associated with lower mortality. Lipid-lowering therapy does not reduce all-cause mortality or cardiovascular (CV) mortality. Lipoproteins play a role in the innate immune system. Our objective was to determine whether protection from infection might counterbalance adverse CV outcomes associated with lipoproteins. Methods We examined associations between serum apolipoprotein (Apo) A1, B, C2, C3, high-density lipoprotein and low-density lipoprotein (LDL) cholesterol and triglyceride levels and infectious mortality or hospitalization, CV mortality or hospitalization, and all-cause mortality in 433 prevalent HD patients. Cox models with time-varying apolipoprotein concentrations collected every 6 months for up to 2 years were used for analyses. Results Median follow-up time for all-cause mortality was 2.7 years (25th–75th percentile range: 2.2–3.4 years). One hundred seventy-nine (41%) patients had an infection-related event. In multivariable models, higher Apo B and LDL were associated with lower risks of infection-related outcomes (hazard ratio Apo B 0.92 [95% confidence interval 0.86–0.99 per 10 mg/dL, P = .03]; hazard ratio LDL 0.93 [95% confidence interval 0.87–1.00 per 10 mg/dL, P = .05]). Sixty-three (15%) participants had a CV-related event. No significant associations were observed between lipoproteins and CV outcomes. Eighty-seven (20%) participants died. Higher Apo A1, Apo B, and Apo C3 were associated with lower risks of all-cause mortality. There was no interaction between the use of lipid-lowering medication and any of the outcomes. Conclusion Associations of lipoproteins with lower risk of serious infection accompanied by no significant association with CV events may help to explain the paradoxical association between lipids and survival and lack of benefit of lipid-lowering therapies in HD.

Trauma Informed Care (TIC) acknowledges the presence and effects of trauma in the lives of many mental health service users and the responsibility of services to provide physical and emotional safety. One challenge of TIC is a lack of clarity about translating the philosophy into practice. This paper describes the delivery and evaluation of a trauma informed communication workshop for mental health nurses that aimed to increase their knowledge of the potential impacts of trauma on consumers, and translate TIC concepts into their communication approaches within the therapeutic relationship.

Background and objectives Frailty is common among patients on hemodialysis and associated with adverse outcomes. However, little is known about changes in frailty over time and the factors associated with those changes. Design, setting, participants, & measurements To address these questions, we examined 762 participants in the A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD cohort study, among whom frailty was assessed at baseline and 12 and 24 months. We used ordinal generalized estimating equations analyses and modeled frailty (on a scale from zero to five possible components) and death during follow-up. Results The mean frailty score at baseline was 1.9, and the distribution of frailty scores was similar at each evaluation. However, most participants’ scores changed, with patients improving almost as often as worsening (overall change, 0.2 points per year; 95% confidence interval, 0.1 to 0.3). Hispanic ethnicity (0.6 points per year; 95% confidence interval, 0.0 to 1.1) and diabetes (0.7 points per year; 95% confidence interval, 0.3 to 1.0) were associated with higher frailty scores and higher serum albumin concentration with lower frailty scores (−1.1 points per g/dl; 95% confidence interval, −1.5 to −0.7). In addition, patients whose serum albumin increased over time were less likely to become frail, with each 1-g/dl increase in albumin associated with a 0.4-point reduction in frailty score (95% confidence interval, −0.80 to −0.05). To examine the underpinnings of the association between serum albumin and frailty, we included serum IL-6, normalized protein catabolic rate, and patient self-report of hospitalization within the last year in a second model. Higher IL-6 and hospitalization were statistically significantly associated with worse frailty at any point and worsening frailty over time, whereas normalized protein catabolic rate was not independently associated with frailty. Conclusions There was substantial year to year variability in frailty scores, with approximately equal numbers of patients improving and worsening. Markers of inflammation and hospitalization were independently associated with worsening frailty. Studies should examine whether interventions to address inflammation or posthospitalization rehabilitation can improve the trajectory of frailty. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_06_06_Johansen.mp3

Background The emotional labour of nursing work involves managing the emotional demands of relating with patients, families and colleagues. Building nurses' resilience is an important strategy in mitigating the stress and burnout that may be caused by ongoing exposure to these demands. Understandings of resilience in the context of emotional labour in nursing, however, are limited. Objectives To investigate the state of knowledge on resilience in the context of emotional labour in nursing. Design Integrative literature review. Data sources CINAHL, Medline, Scopus, and PsycINFO electronic databases were searched for abstracts published between 2005 and 2015 and written in English. Reference lists were hand searched. Review methods Whittemore and Knafl's integrative review method was used to guide this review. The constant comparative method was used to analyze and synthesize data from 27 peer-reviewed quantitative and qualitative articles. Methodological quality of included studies was assessed using the Mixed Methods Assessment Tool. Results Emotional labour is a facet of all aspects of nursing work and nurse-patient/family/collegial interactions. Emotional dissonance arising from surface acting in emotional labour can lead to stress and burnout. Resilience can be a protective process for the negative effects of emotional labour. Several resilience interventions have been designed to strengthen nurses' individual resources and reduce the negative effects of workplace stress; however they do not specifically address emotional labour. Inclusion of emotional labour-mitigating strategies is recommended for future resilience interventions. Conclusion Resilience is a significant intervention that can build nurses' resources and address the effects of emotional dissonance in nursing work. There is a need for further investigation of the relationship between resilience and emotional labour in nursing, and robust evaluation of the impact of resilience interventions that address emotional labour.

Background Understanding the extent to which visceral and subcutaneous body fat are associated with markers of nutrition and inflammation in patients on dialysis therapy could shed light on the obesity paradox and the biology of subcutaneous fat. Study Design Cross-sectional. Setting & Participants 609 adults receiving hemodialysis who participated in the ACTIVE/ADIPOSE Study. Predictors Body mass index (BMI), waist circumference, and bioelectrical impedance spectroscopy−derived estimates of percent body fat. Outcomes C-Reactive protein (CRP), interleukin 6 (IL-6), prealbumin, albumin, leptin, and adiponectin concentrations. Measurements We performed linear regression analyses to examine the extent to which proxies of visceral and subcutaneous fat were associated with inflammation, nutrition, and adiposity-related hormones. Results BMI was directly associated with markers of inflammation (standardized estimate for ln[CRP in mg/L]: 0.30 [95% CI, 0.22-0.38] per 10kg/m2; for ln[IL-6 in pg/mL]: 0.10 [95% CI, 0.02-0.18] per 10kg/m2), but was not associated with markers of nutrition. BMI was also inversely associated with adiponectin and directly associated with leptin. With waist circumference and percent body fat (as a proxy of visceral and subcutaneous fat, respectively) modeled together, waist circumference was associated with markers of inflammation (standardized estimate for ln[CRP in mg/L]: 0.21 [95% CI, 0.09-0.34] per 10cm; for ln[IL-6 in pg/mL]: 0.18 [95% CI, 0.07-0.29] per 10cm), whereas percent body fat was not associated with CRP (standardized estimate for ln[CRP in mg/L]: 0.03 [95% CI, −0.10 to 0.15] per 1%) and was inversely associated with IL-6 (standardized estimate for ln[IL-6 in pg/mL]: −0.15 [95% CI, −0.27 to −0.02] per 1%). In addition, waist circumference was inversely associated with prealbumin and albumin (standardized estimates of −0.12 [95% CI, −0.23 to −0.02] mg/dL per 10cm and −0.17 [95% CI, −0.28 to −0.06] g/dL per 10cm, respectively), and percent body fat was directly associated with prealbumin and albumin (0.20 [95% CI, 0.07-0.32] mg/dL and 0.15 [95% CI, 0.02-0.28] g/dL per 1%, respectively). Higher waist circumference was associated indirectly with adiponectin and directly with leptin concentrations. Limitations Although the observed associations implicate visceral fat as the cause of inflammation, it cannot be determined in this cross-sectional study. Conclusions Proxies of visceral and subcutaneous fat appear to have opposing associations with biomarkers of inflammation and nutrition. Subcutaneous fat may be an indicator of nutritional status, and visceral fat, an indicator of inflammation.

ObjectiveTo test the performance of appetite assessment tools among patients receiving hemodialysis (HD).DesignCross-sectional.SubjectsTwo hundred twenty-one patients receiving HD enrolled in seven dialysis facilities in Northern California.InterventionWe assessed 5 appetite assessment tools (self-assessment of appetite, subjective assessment of appetite, visual analog scale [VAS], Functional Assessment of Anorexia/Cachexia Therapy [FAACT] score, and the Anorexia Questionnaire [AQ]).Main outcome measuresReported food intake, normalized protein catabolic rate, and change in body weight were used as criterion measures, and we assessed associations among the appetite tools and biomarkers associated with nutrition and inflammation. Patients were asked to report their appetite and the percentage of food eaten (from 0% to 100%) during the last meal compared to usual intake.ResultsFifty-eight (26%) patients reported food intake ≤ 50% (defined as poor appetite). The prevalence of anorexia was 12% by self-assessment of appetite, 6% by subjective assessment of appetite, 24% by VAS, 17% by FAACT score, and 12% by AQ. All the tools were significantly associated with food intake ≤ 50% (P < .001), except self-assessment of appetite. The FAACT score and the VAS had the strongest association with food intake ≤ 50% (C-statistic 0.80 and 0.76). Patients with food intake ≤ 50% reported weight loss more frequently than patients without low intake (36% vs 22%) and weight gain less frequently (19% vs 35%; P = .03). Normalized protein catabolic rate was lower among anorexic patients based on the VAS (1.1 ± 0.3 vs 1.2 ± 0.3, P = .03). Ln interleukin-6 correlated inversely with food intake (P = .03), but neither interleukin-6 nor C-reactive protein correlated with any of the appetite tools. Furthermore, only the self-assessment of appetite was significantly associated with serum albumin (P = .02), prealbumin (P = .02) and adiponectin concentrations (P = .03).ConclusionsAlternative appetite assessment tools yielded widely different estimates of the prevalence of anorexia in HD. When considering self-reported food intake as the criterion standard for anorexia, the FAACT score and VAS discriminated patients reasonably well.

Physical health in people with mental illness is often compromised. Chronic physical conditions and disease risk factors occur at higher rates than in the general population. Although substantial research exists regarding mental-physical comorbidities in middle to older-aged adults and mental illness consequential to childhood physical illness, research addressing physical health in young people/emerging adults of 16-24 years with primary mental illnesses is minimal. Health problems often track from youth to adulthood, indicating a need to better recognize and understand the overall health of young people with mental illness. This paper reports findings from an integrative review of published research investigating physical health of emerging/young adults with mental illness. A total of 18 research papers were systematically analysed. The review found that comorbid mental-physical illness/conditions were evident across a wide age span. Specific physical health problems, including pain, gastrointestinal, and respiratory disorders, were apparent in those 16 years to those in their mid-late 20s, and/or with first episode psychosis. Lifestyle risk factors for cardiometabolic disorders occurred with some frequency and originated prior to adulthood. These findings highlight the need for targeted health screening and illness prevention strategies for emerging/young adults with mental health problems and draws attention to the need for young people to be supported in their health-care behaviours.

BackgroundUse of serum creatinine to estimate GFR may lead to underestimation of the association between self-reported frailty and kidney function. Our objectives were to evaluate the association of measured GFR (mGFR) with self-reported frailty among patients with CKD and to determine whether self-reported frailty was associated with death after adjusting for mGFR.MethodsParticipants in the Modification of Diet in Renal Disease study (1989-1993) had GFR measured using iothalamate clearance (mGFR), and GFR was estimated based on the CKD-EPI creatinine (eGFRcr) and cystatin C (eGFRcys) equations. We defined self-reported frailty as three or more of: exhaustion, poor physical function, low physical activity, and low body weight. Death was ascertained through 2007 using the National Death Index and the United States Renal Data System.ResultsEight hundred twelve MDRD participants (97 %) had complete data on self-reported frailty (16 % prevalence, N = 130) and mGFR (mean (SD) 33.1 ± 11.7 ml/min/1.73 m(2)). Higher GFR was associated with lower odds of self-reported frailty based on mGFR, (OR 0.71, 95 % CI 0.60-0.86 per 10 ml/min/1.73 m(2)), eGFRcr (OR 0.80, 95 % CI 0.67-0.94 per 10 ml/min/1.73 m(2)), and eGFRcys (OR 0.75, 95 % CI 0.62-0.90 per 10 ml/min/1.73 m(2)). Median follow-up was 17 (IQR 11-18) years, with 371 deaths. Self-reported frailty was associated with a higher risk of death (HR 1.71, 95 % CI 1.26-2.30), which was attenuated to a similar degree when mGFR (HR 1.48, 95 % CI 1.08-2.00), eGFRcr (HR 1.57, 95 % CI 1.15-2.10), or eGFRcys (HR 1.51, 95 % CI 1.10-2.10) was included as an indicator of kidney function.ConclusionsWe found an inverse association between kidney function and self-reported frailty that was similar for mGFR, eGFR and eGFRcys. In this relatively healthy cohort of clinical trial participants with CKD, using serum creatinine to estimate GFR did not substantially alter the association of GFR with self-reported frailty or of self-reported frailty with death.

Compromised physical health and raised levels of morbidity and mortality are experienced by young people (16-24 years) with mental illness, and are compounded by psychotropic medication. How this group conceives and experiences physical health is not well understood. We investigated the meanings, beliefs, and endeavours of young people that impact their physical health understandings and behaviours. The present study formed the qualitative phase of a sequential mixed-methods study, and incorporated semistructured interviews with 12 hospitalized young people. Qualitative content analysis was used to analyse data. Participants held a holistic ideal of physical health that they did not meet. Weight change, poor sleep, and limited exercise adversely impacted their lives and self-image. Sedentary behaviour, reduced energy, and limited health literacy compromised effective management of physical health. Young people needed structure and support to assist them in addressing their physical health needs when amotivation overwhelmed their internal resources. Nurses are well placed to help young people increase their competency for health management. Individualized information and methods to promote good physical health are required for this group in jeopardy from physical morbidity and mortality.

Background and objectives Frailty is common among patients on dialysis and increases vulnerability to dependency and death. Design, setting, participants, & measurements We examined the predictive ability of frailty on the basis of physical performance and self-reported function in participants of a US Renal Data System special study that enrolled a convenience sample of 771 prevalent patients on hemodialysis from 14 facilities in the Atlanta and northern California areas from 2009 to 2011. Performance-based frailty was assessed using direct measures of grip strength (weakness) and gait speed along with weight loss, exhaustion, and low physical activity; poor self–reported function was substituted for weakness and slow gait speed in the self–reported function–based definition. For both definitions, patients meeting three or more criteria were considered frail. Results The mean age of 762 patients included in analyses was 57.1±14.2 years old; 240 patients (31%) met the physical performance–based definition of frailty, and 396 (52%) met the self–reported function–based definition. There were 106 deaths during 1.7 (interquartile range, 1.4–2.4) years of follow-up. After adjusting for demographic and clinical characteristics, the hazard ratio (HR) for mortality for the performance-based definition (2.16; 95% confidence interval [95% CI], 1.41 to 3.29) was slightly higher than that of the self–reported function–based definition (HR, 1.93; 95% CI, 1.24 to 3.00). Patients who met the self-report–based definition but not the physical performance definition of frailty (n=192) were not at statistically significantly higher risk of mortality than those who were not frail by either definition (n=330; HR, 1.41; 95% CI, 0.81 to 2.45), but those who met both definitions of frailty (n=204) were at significantly higher risk (HR, 2.46; 95% CI, 1.51 to 4.01). Conclusions Frailty, defined using either direct tests of physical performance or self–reported physical function, was associated with higher mortality among patients receiving hemodialysis. Future studies are needed to determine the utility of assessing frailty in clinical practice.

Delayed graft function (DGF) is a frequent complication of renal transplantation, particularly in the setting of transplantation of kidneys derived from deceased donors and expanded-criteria donors. DGF results from tubular epithelial cell injury and has immediate and long term consequences. These include requirement for post-transplantation dialysis, increased incidence of acute rejection, and poorer long-term outcomes. DGF represents one of the clearest clinical examples of renal acute ischemia/reperfusion injury. Experimental studies have demonstrated that ischemia/reperfusion injury induces the synthesis of the full length secreted isoform of matrix metalloproteinase-2 (FL-MMP-2), as well as an intracellular N-terminal truncated MMP-2 isoform (NTT-MMP-2) that initiates an innate immune response. We hypothesized that the two MMP-2 isoforms mediate tubular epithelial cell injury in DGF. Archival renal biopsy sections from 10 protocol biopsy controls and 41 cases with a clinical diagnosis of DGF were analyzed for the extent of tubular injury, expression of the FL-MMP-2 and NTT-MMP-2 isoforms by immunohistochemistry (IHC), in situ hybridization, and qPCR to determine isoform abundance. Differences in transcript abundance were related to tubular injury score. Markers of MMP-2-mediated injury included TUNEL staining and assessment of peritubular capillary density. There was a clear relationship between tubular epithelial cell expression of both FL-MMP-2 and NTT-MMP-2 IHC with the extent of tubular injury. The MMP-2 isoforms were detected in the same tubular segments and were present at sites of tubular injury. qPCR demonstrated highly significant increases in both the FL-MMP-2 and NTT-MMP-2 transcripts. Statistical analysis revealed highly significant associations between FL-MMP-2 and NTT-MMP-2 transcript abundance and the extent of tubular injury, with NTT-MMP-2 having the strongest association. We conclude that two distinct MMP-2 isoforms are associated with tubular injury in DGF and offer novel therapeutic targets for the prevention of this disorder.