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The U.S. is the main country in the world that delivers its food assistance primarily via transoceanic shipments of commodity-based in-kind food. This approach is costlier and less timely than cash-based assistance, which includes cash transfers, food vouchers, and local and regional procurement, where food is bought in or nearby the recipient country. The U.S.'s approach is exacerbated by a requirement that half of its transoceanic food shipments need to be sent on U.S.-flag vessels. We estimate the effect of these U.S. food assistance distribution policies on child mortality in northern Kenya by formulating and optimizing a supply chain model. In our model, monthly orders of transoceanic shipments and cash-based interventions are chosen to minimize child mortality subject to an annual budget constraint and to policy constraints on the allowable proportions of cash-based interventions and non-US-flag shipments. By varying the restrictiveness of these policy constraints, we assess the impact of possible changes in U.S. food aid policies on child mortality. The model includes an existing regression model that uses household survey data and geospatial data to forecast the mean mid-upper-arm circumference Z scores among children in a community, and allows food assistance to increase Z scores, and Z scores to influence mortality rates. We find that cash-based interventions are a much more powerful policy lever than the U.S.-flag vessel requirement: switching to cash-based interventions reduces child mortality from 4.4% to 3.7% (a 16.2% relative reduction) in our model, whereas eliminating the U.S.-flag vessel restriction without increasing the use of cash-based interventions generates a relative reduction in child mortality of only 1.1%. The great majority of the gains achieved by cash-based interventions are due to their reduced cost, not their reduced delivery lead times; i.e., the reduction of shipping expenses allows for more food to be delivered, which reduces child mortality., Competing Interests: The authors have declared that no competing interests exist.

Background and Objectives: The majority of older adults who initiate dialysis do so during a hospitalization, and these patients may require post-acute skilled nursing facility (SNF) care. For these patients, a focus on nondisease-specific problems, including cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy, may be more relevant to outcomes than the traditional disease-oriented approach. However, the association of the burden of nondisease-specific problems with mortality, transition to long-term care (LTC), and functional impairment among older adults receiving SNF care after dialysis initiation has not been studied., Design, Setting, Participants, & Measurements: We identified 40,615 Medicare beneficiaries ≥65 years old who received SNF care after dialysis initiation between 2000 and 2006 by linking renal disease registry data with the Minimum Data Set. Nondisease-specific problems were ascertained from the Minimum Data Set. We defined LTC as ≥100 SNF days and functional impairment as dependence in all four essential activities of daily living at SNF discharge. Associations of the number of nondisease-specific problems (≤1, 2, 3, and 4-6) with 6-month mortality, LTC, and functional impairment were examined., Results: Overall, 39.2% of patients who received SNF care after dialysis initiation died within 6 months. Compared with those with ≤1 nondisease-specific problems, multivariable adjusted hazard ratios (95% confidence interval) for mortality were 1.26 (1.19 to 1.32), 1.40 (1.33 to 1.48), and 1.66 (1.57 to 1.76) for 2, 3, and 4-6 nondisease-specific problems, respectively. Among those who survived, 37.1% required LTC; of those remaining who did not require LTC, 74.7% had functional impairment. A higher likelihood of transition to LTC (among those who survived 6 months) and functional impairment (among those who survived and did not require LTC) was seen with a higher number of problems., Conclusions: Identifying nondisease-specific problems may help patients and families anticipate LTC needs and functional impairment after dialysis initiation., (Copyright © 2016 by the American Society of Nephrology.)

The biodiversity-productivity relationship (BPR) is foundational to our understanding of the global extinction crisis and its impacts on ecosystem functioning. Understanding BPR is critical for the accurate valuation and effective conservation of biodiversity. Using ground-sourced data from 777,126 permanent plots, spanning 44 countries and most terrestrial biomes, we reveal a globally consistent positive concave-down BPR, showing that continued biodiversity loss would result in an accelerating decline in forest productivity worldwide. The value of biodiversity in maintaining commercial forest productivity alone-US$166 billion to 490 billion per year according to our estimation-is more than twice what it would cost to implement effective global conservation. This highlights the need for a worldwide reassessment of biodiversity values, forest management strategies, and conservation priorities., (Copyright © 2016, American Association for the Advancement of Science.)

Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management., Competing Interests: Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Rasheeda K. Hall, Carol Haines, Steven M. Gorbatkin, Lynn Schlanger, Hesham Shaban, Jane O. Schell, Susan B. Gurley, Cathleen S. Colón-Emeric, C. Barrett Bowling, (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objective: To examine whether older age was associated with lower health-related quality of life (HRQOL) among patients with systemic lupus erythematosus (SLE) and whether differential disease-related damage and activity explained these associations., Methods: We used cross-sectional data on 684 patients with SLE aged ≥20 years from the Georgians Organized Against Lupus cohort to estimate the associations between age (categorised as 20-39, 40-59 and ≥60 years) and HRQOL (Short Form-12 norm-based domain and physical component summary (PCS) and mental component summary (MCS) scores), using multivariable linear regression. We then examined the effect of disease-related damage and activity on these associations., Results: The mean age of the cohort was 48.2±13.1 years (range, 20-88 years), with 28.0%, 52.9% and 19.1% of participants being aged 20-39, 40-59 and ≥60 years, respectively; 79.0% were African-American and 93.7% were female. The mean PCS score was 39.3 (41.8, 38.7 and 37.4 among those aged 20-39, 40-59 and ≥60 years, respectively), while the mean MCS score was 44.3 (44.2, 43.8 and 46.1, respectively). In general, lower physical but not mental HRQOL scores were associated with older age. With adjustment, older ages (40-59 and ≥60, respectively, vs 20-39) remained associated (β (95% CI)) with lower PCS (-2.53 (-4.58 to -0.67) and -3.57 (-6.19 to -0.96)) but not MCS (0.47 (-1.46 to 2.41) and 1.20 (-1.52 to 3.92)) scores. Associations of age with HRQOL domain and summary scores were not substantially changed by further adjustment for disease-related damage and/or activity., Conclusions: Nearly one in five participants in this large, predominantly African-American cohort of patients with SLE was at least 60 years old. The associations of older age with lower physical, but not mental, HRQOL were independent of accumulated SLE damage and current SLE activity. The results suggest that studies of important geriatric outcomes in the setting of SLE are needed to inform patient-centred clinical care of the ageing SLE population.

Background and Objectives: Falls are common and associated with adverse outcomes in patients on dialysis. Limited data are available in earlier stages of CKD., Design, Setting, Participants, & Measurements: We analyzed data from 8744 Reasons for Geographic and Racial Differences in Stroke Study participants ≥65 years old with Medicare fee for service coverage. Serious fall injuries were defined as a fall-related fracture, brain injury, or joint dislocation using Medicare claims. Hazard ratios (HRs) for serious fall injuries were calculated by eGFR and albumin-to-creatinine ratio (ACR). Among 2590 participants with CKD (eGFR<60 ml/min per 1.73 m(2) or ACR≥30 mg/g), cumulative mortality after a serious fall injury compared with age-matched controls without a fall injury was calculated., Results: Overall, 1103 (12.6%) participants had a serious fall injury over 9.9 years of follow-up. The incidence rates per 1000 person-years of serious fall injuries were 21.7 (95% confidence interval [95% CI], 20.3 to 23.2), 26.6 (95% CI, 22.6 to 31.3), and 38.3 (95% CI, 31.2 to 47.0) at eGFR levels ≥60, 45-59, and <45 ml/min per 1.73 m(2), respectively, and 21.3 (95% CI, 20.0 to 22.8), 31.7 (95% CI, 27.5 to 36.5), and 42.2 (95% CI, 31.3 to 56.9) at ACR levels <30, 30-299, and ≥300 mg/g, respectively. Multivariable adjusted HRs for serious fall injuries were 0.91 (95% CI, 0.76 to 1.09) and 1.09 (95% CI, 0.86 to 1.37) for eGFR=45-59 and <45 ml/min per 1.73 m(2), respectively, versus eGFR≥60 ml/min per 1.73 m(2) and 1.31 (95% CI, 1.11 to 1.54) and 1.81 (95% CI, 1.30 to 2.50) for ACR=30-299 and ≥300 mg/g, respectively, versus ACR<30 mg/g. Among participants with CKD, cumulative 1-year mortality rates among patients with a serious fall and age-matched controls were 21.0% and 5.5%, respectively., Conclusions: Elevated ACR but not lower eGFR was associated with serious fall injuries. Evaluation for fall risk factors and fall prevention strategies should be considered for older adults with elevated ACR., (Copyright © 2016 by the American Society of Nephrology.)

The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting real-world treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patient-centered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives., (Published by Oxford University Press on behalf of ERA-EDTA 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Current guidelines suggest using cystatin-C to confirm a reduced creatinine-based estimated glomerular filtration rate (eGFRcr) when the latter is thought to be inaccurate. Older adults have reduced muscle mass, which may affect the accuracy of eGFRcr. We evaluated the use of cystatin-C-based eGFR (eGFRcys) to confirm reduced eGFRcr among adults ≥ 80 years of age and, for comparison, younger adults., Material and Methods: We analyzed data from 3,059 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants with reduced eGFRcr (< 60 ml/min/1.73 m(2)) enrolled in 2003-2007 who were not on dialysis. eGFRcr and eGFRcys were calculated using age, sex and race-adjusted equations. Confirmed reduced eGFRcr was defined as eGFRcys < 60 ml/min/1.73 m(2). Prevalence of chronic kidney disease complications at baseline and all-cause mortality up to March 2012 were calculated. Analyses were stratified by age: < 65, 65-79 and ≥ 80 years., Results: Among participants < 65, 65-79 and ≥ 80 years of age, 76.5%, 85.7% and 92.5%, respectively, had reduced eGFRcr confirmed with eGFRcys (p < 0.001). Among participants ≥ 80 years of age, those with reduced eGFRcr confirmed with eGFRcys had higher prevalence of hypertension (79.1% vs. 65.1%, p = 0.03) and albuminuria (38.3% vs. 22.7%, p = 0.04) and higher risk for all-cause mortality (hazard ratio: 2.43; 95% confidence interval: 1.19-5.01) as compared with those in whom reduced eGFRcr was not confirmed by eGFRcys., Conclusions: Reduced eGFRcr was confirmed using eGFRcys for the vast majority of adults ≥ 80 years. These results suggest that using cystatin-C to confirm a reduced eGFRcr may not be necessary among the oldest old.

Many adults with elevated clinic blood pressure (BP) have lower BP when measured outside the clinic. This phenomenon, the "white-coat effect," may be larger among older adults, a population more susceptible to the adverse effects of low BP. The authors analyzed data from 257 participants in the Jackson Heart Study with elevated clinic BP (systolic/diastolic BP [SBP/DBP] ≥140/90 mm Hg) who underwent ambulatory BP monitoring (ABPM). The white-coat effect for SBP was larger for participants 60 years and older vs those younger than 60 years in the overall population (12.2 mm Hg, 95% confidence interval [CI], 9.2-15.1 mm Hg and 8.4 mm Hg, 95% CI, 5.7-11.1, respectively; P=.06) and among those without diabetes or chronic kidney disease (15.2 mm Hg, 95% CI, 10.1-20.2 and 8.6 mm Hg, 95% CI, 5.0-12.3, respectively; P=.04). After multivariable adjustment, clinic SBP ≥150 mm Hg vs <150 mm Hg was associated with a larger white-coat effect. Studies are needed to investigate the role of ABPM in guiding the initiation and titration of antihypertensive treatment, especially among older adults., (©2015 Wiley Periodicals, Inc.)

The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.

It is unclear if patients who have atrial fibrillation (AF) have a greater fall risk compared with those in the general population and if falls increase mortality beyond that observed in AF. A total of 24,117 (mean age 65 ± 9.3 years; 55% women; 38% black) participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were included. AF was identified from baseline electrocardiogram data and by self-reported history. Falls were considered present if participants reported ≥2 falls within the year before the baseline examination. Logistic regression was used to examine the relationship between prevalent AF and falls. Cox regression was used to examine the risk of death in those with AF and falls, separately and in combination, compared with those without either condition. A total of 2,007 participants (8.3%) had baseline AF and 1,655 (6.7%) reported falls. A higher prevalence of falls was reported in those with AF (n = 209; 10%) than those without AF (n = 1,446; 6.5%; p <0.0001). After adjustment for fall risk factors, AF was significantly associated with falls (odds ratio 1.22, 95% confidence interval [CI] 1.04 to 1.44). Compared with no history of AF or falls, the concomitant presence of AF and falls (hazard ratio [HR] 2.12, 95% CI 1.64 to 2.74) was associated with a greater risk of death than AF (HR 1.44, 95% CI 1.28 to 1.62) or falls (HR 1.61, 95% CI 1.42 to 1.82). In conclusion, patients with AF are more likely to report a history of falls in REGARDS. Additionally, participants with AF who report falls have an increased risk of death than those with either condition in isolation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The usage of nursing home (NH) services is a marker of frailty among older adults. Although the Centers for Medicare & Medicaid Services (CMS) revised the Medical Evidence Report Form CMS-2728 in 2005 to include data collection on NH institutionalization, the validity of this item has not been reported., Methods: There were 27,913 patients ≥ 75 years of age with incident end-stage renal disease (ESRD) in 2006, which constituted our analysis cohort. We determined the accuracy of the CMS-2728 using a matched cohort that included the CMS Minimum Data Set (MDS) 2.0, often employed as a "gold standard" metric for identifying patients receiving NH care. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the CMS-2728 NH item. Next, we compared characteristics and mortality risk by CMS-2728 and MDS NH status agreement., Results: The sensitivity, specificity, PPV and NPV of the CMS-2728 for NH status were 33%, 97%, 80% and 79%, respectively. Compared to those without the MDS or CMS-2728 NH indicator (No MDS/No 2728), multivariable adjusted hazard ratios (95% confidence interval) for mortality associated with NH status were 1.55 (1.46 - 1.64) for MDS/2728, 1.48 (1.42 - 1.54) for MDS/No 2728, and 1.38 (1.25 - 1.52) for No MDS/2728. NH utilization was more strongly associated with mortality than other CMS-2728 items in the model., Conclusions: The CMS-2728 underestimated NH utilization among older adults with incident ESRD. The potential for misclassification may have important ramifications for assessing prognosis, developing advanced care plans and providing coordinated care.

Background: Health care claims data may provide a cost-efficient approach for studying chronic kidney disease (CKD)., Study Design: Prospective cohort study., Setting & Participants: We compared characteristics and outcomes for individuals with CKD defined using laboratory measurements versus claims data from 6,982 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants who had Medicare fee-for-service coverage., Predictors: Presence of CKD as defined by both the REGARDS Study (CKDREGARDS) and Medicare data (CKDMedicare), presence of CKDREGARDS but not CKDMedicare, and presence of CKDMedicare but not CKDREGARDS, and absence of both CKDREGARDS and CKDMedicare., Outcomes: Mortality and incident end-stage renal disease (ESRD)., Measurements: The research study definition of CKD (CKDREGARDS) included estimated glomerular filtration rate (eGFR) < 60mL/min/1.73m(2) or albumin-creatinine ratio > 30mg/g at the REGARDS Study visit. CKD in Medicare (CKDMedicare) was identified during the 2 years before each participant's REGARDS visit using a claims-based algorithm., Results: Overall, 32% of participants had CKDREGARDS and 6% had CKDMedicare. Sensitivity, specificity, and positive and negative predictive values of CKDMedicare for identifying CKDREGARDS were 15.5% (95% CI, 14.0%-17.1%), 97.7% (95% CI, 97.2%-98.1%), 75.6% (95% CI, 71.4%-79.5%), and 71.5% (95% CI, 70.4%-72.6%), respectively. Mortality and ESRD incidence rates, expressed per 1,000 person-years, were higher for participants with versus without CKDMedicare (mortality: 72.5 [95% CI, 61.3-83.7] vs 33.3 [95% CI, 31.5-35.2]; ESRD: 16.4 [95% CI, 11.2-21.6] vs 1.3 [95% CI, 0.9-1.6]) and with versus without CKDREGARDS (mortality: 59.9 [95% CI, 55.4-64.4] vs 25.5 [95% CI, 23.6-27.4]; ESRD: 6.8 [95% CI, 5.4-8.3] vs 0.1 [95% CI, 0.0-0.3]). Among participants with CKDREGARDS, those with abdominal obesity, diabetes, anemia, lower eGFR, more outpatient visits, hospitalization, and a nephrologist visit in the 2 years before their REGARDS visit were more likely to have CKDMedicare., Limitations: CKDREGARDS relied on eGFR and albuminuria assessed at a single visit., Conclusions: CKD, whether defined in claims or through research study measurements, was associated with increased mortality and ESRD. However, individuals with CKD identified in claims may represent a select high-risk population., (Copyright © 2015 National Kidney Foundation, Inc. All rights reserved.)

We advance a theory of resilience as it applies to the challenges of international development. The conceptualization we advance for development resilience focuses on the stochastic dynamics of individual and collective human well-being, especially on the avoidance of and escape from chronic poverty over time in the face of myriad stressors and shocks. Development resilience clearly nests within it the related but distinct idea of humanitarian resilience and thereby offers a conceptual apparatus to integrate the humanitarian and development ambitions. We discuss the implications for programming, systems integration, and measurement.

Background and Objectives: The term "nondisease-specific" has been used to describe problems that cross multiple domains of health and are not necessarily the result of a single underlying disease. Although individuals with reduced eGFR and elevated albumin-to-creatinine ratio have many comorbidities, the prevalence of and outcomes associated with nondisease-specific problems have not been well studied., Design, Setting, Participants, & Measurements: Participants included 3557 black and white United States adults ≥75 years of age from the Reasons for Geographic and Racial Differences in Stroke Study. Nondisease-specific problems included cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy. Hazard ratios for mortality over a median (interquartile range) of 5.4 (4.2-6.9) years of follow-up associated with one, two, or three to six nondisease-specific problems were calculated and stratified by eGFR (≥60, 45-59, and <45 ml/min per 1.73 m(2)) and separately, albumin-to-creatinine ratio (<30, 30-299, and ≥300 mg/g). Secondary outcomes included hospitalizations and emergency department visits over 1.8 (0.7-4.0) and 2.3 (0.9-4.7) years of follow-up, respectively., Results: The prevalence of nondisease-specific problems was more common at lower eGFR and higher albumin-to-creatinine ratio levels. Within each eGFR and albumin-to-creatinine ratio strata, the risk for mortality was higher among those with a greater number of nondisease-specific problems. For example, among those with an eGFR=45-59 ml/min per 1.73 m(2), the multivariable adjusted hazard ratios (95% confidence intervals) for mortality associated with one, two, or three to six nondisease-specific problems were 1.17 (0.78 to 1.76), 1.95 (1.24 to 3.07), and 2.44 (1.39 to 4.27; P trend <0.001). Risk for hospitalization and emergency department visits was higher among those with more nondisease-specific problems within eGFR and albumin-to-creatinine ratio strata., Conclusions: Among older adults, nondisease-specific problems commonly co-occur with reduced eGFR and elevated albumin-to-creatinine ratio. Identification of nondisease-specific problems may provide mortality risk information independent of measures of kidney function., (Copyright © 2014 by the American Society of Nephrology.)

Background: The prevalence of reduced estimated glomerular filtration rate (eGFR) among U.S. adults aged 80 years and older increased between 1988 to 1994 and 2005 to 2010. Trends in the prevalence of albuminuria over this time period have not been reported in this population., Methods: We conducted a cross-sectional analysis of U.S. adults aged 80 years and older in the National Health and Nutrition Examination Survey 1988 to 1994 (n = 1020), 1999 to 2004 (n = 995) and 2005 to 2010 (n = 971) to calculate the prevalence of albuminuria (albumin-to-creatinine ratio [ACR] ≥30 mg/g) by calendar period. The number of U.S. adults aged 80 years and older with elevated ACR and separately reduced eGFR was calculated by calendar period., Results: Among participants aged 80 years and older, the prevalence of albuminuria was 30.9%, 33.0% and 30.6% in 1988 to 1994, 1999 to 2004 and 2005 to 2010 (P = 0.9). The proportion of U.S. adults aged 80 years and older with both eGFR <45 ml/min/1.73 m and ACR ≥30 mg/g increased from 6.8% in 1988 to 1994 to 8.4% and 9.5% in 1999 to 2004 and 2005 to 2010, respectively (P = 0.008). In 1988 to 1994, 1999 to 2004 and 2005 to 2010, there were 1.78 (95% confidence interval [CI], 1.29-2.27), 2.35 (95% CI, 1.93-2.78) and 2.74 (95% CI, 2.32-3.16) million U.S. adults aged 80 years older with albuminuria and 2.34 (95% CI, 1.79-2.89), 3.55 (95% CI, 2.96-4.14) and 4.58 (95% CI, 3.87-5.28) million, respectively, with eGFR <60 ml/min/1.73 m., Conclusions: The proportion of U.S. adults aged 80 years and older with an elevated ACR remained relatively stable between 1988 to 1994 and 2005 to 2010. However, due to the growth of the oldest-old, the absolute number with albuminuria increased substantially over the past 2 decades.

The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) was recently published. This guideline recommended that older adults (≥60 years) without diabetes or chronic kidney disease with systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg be initiated on antihypertensive medication with a treatment goal SBP/DBP <150/90 mm Hg. In contrast, the previous 3 JNC guidelines recommended treatment for these individuals be initiated at SBP/DBP ≥140/90 mm Hg with goal SBP/DBP <140/90 mm Hg. In this article, we review randomized trials of antihypertensive medication and observational data on SBP and DBP with cardiovascular outcomes among older adults, possible explanations underlying the different findings from these randomized trials and observational studies, and contemporary antihypertensive treatment patterns among older U.S. adults. In closing, we highlight future research needs related to hypertension and outcomes among older adults.

Background: Studies suggest that treatment-resistant hypertension is common and increasing in prevalence among US adults. Although hypertension is a risk factor for end-stage renal disease (ESRD), few data are available for the association between treatment-resistant hypertension and ESRD risk., Study Design: Prospective cohort study., Setting & Participants: We analyzed data from 9,974 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants treated for hypertension without ESRD at baseline., Predictor: Treatment-resistant hypertension was defined as uncontrolled blood pressure (BP) with concurrent use of 3 antihypertensive medication classes including a diuretic or use of 4 or more antihypertensive medication classes including a diuretic regardless of BP., Outcome: Incident ESRD was identified by linkage of REGARDS Study participants with the US Renal Data System., Measurements: During a baseline in-home study visit, BP was measured twice and classes of antihypertensive medication being taken were determined by pill bottle inspection., Results: During a median follow-up of 6.4 years, there were 152 incident cases of ESRD (110 ESRD cases among 2,147 with treatment-resistant hypertension and 42 ESRD cases among 7,827 without treatment-resistant hypertension). The incidence of ESRD per 1,000 person-years for hypertensive participants with and without treatment-resistant hypertension was 8.86 (95% CI, 7.35-10.68) and 0.88 (95% CI, 0.65-1.19), respectively. After multivariable adjustment, the HR for ESRD comparing hypertensive participants with versus without treatment-resistant hypertension was 6.32 (95% CI, 4.30-9.30). Of participants who developed incident ESRD during follow-up, 72% had treatment-resistant hypertension at baseline., Limitations: BP, estimated glomerular filtration rate, and albuminuria assessed at a single time., Conclusions: Individuals with treatment-resistant hypertension are at increased risk for ESRD. Appropriate clinical management strategies are needed to treat treatment-resistant hypertension in order to preserve kidney function in this high-risk group., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The authors examined trends in systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the prevalence, awareness, treatment, and control of hypertension in 1988-1994 (n=1164), 1999-2004 (n=1,026), and 2005-2010 (n=1048) among US adults 80 years and older in serial National Health and Nutrition Examination Surveys. Hypertension was defined as SBP ≥140 mm Hg, DBP ≥90 mm Hg, or use of antihypertensive medication. Awareness and treatment were defined by self-report and control as SBP/DBP<140/90 mm Hg. Mean SBP decreased from 147.3 mm Hg to 140.1 mm Hg and mean DBP from 70.2 mm Hg to 59.4 mm Hg between 1988-1994 and 2005-2010. The prevalence, awareness, and treatment of hypertension each increased over time. Controlled hypertension increased from 30.4% in 1988-1994 to 53.1% in 2005-2010. The proportion of patients taking 3 classes of antihypertensive medication increased from 7.0% to 30.9% between 1988-1994 and 2005-2010. Increases in awareness, treatment, and control of hypertension and antihypertensive polypharmacy have been observed among very old US adults., (©2014 Wiley Periodicals, Inc.)

Subjective risk perceptions give rise to unique policy implications as they reflect both the expectation of risk exposure and the ability to mitigate or cope with the adverse impacts. Based on data collected from semistructured interviews and iterative ranking exercises with 159 households in the Altay and Tianshan Mountains of Xinjiang, China, this study investigates and explains the risks with respect to a seriously understudied population and location. Using both geostatistical and econometric methods, we show that although fear of environmental crisis is prevalent among our respondents, recently implemented pastoral conservation, sedentarization, and development projects are more likely to be ranked as the top concerns among affected households. In order to reduce these concerns, future pastoral policy must be built on the livestock economy, and intervention priority should be given to the geographic areas identified as risk hot spots. In cases where pastoralists have to give up their pastures, the transition to other comparable livelihood strategies must be enabled by creating new opportunities and training pastoralists to acquire the needed skills., (© 2013 Society for Risk Analysis.)

Understanding why some human populations remain persistently poor remains a significant challenge for both the social and natural sciences. The extremely poor are generally reliant on their immediate natural resource base for subsistence and suffer high rates of mortality due to parasitic and infectious diseases. Economists have developed a range of models to explain persistent poverty, often characterized as poverty traps, but these rarely account for complex biophysical processes. In this Essay, we argue that by coupling insights from ecology and economics, we can begin to model and understand the complex dynamics that underlie the generation and maintenance of poverty traps, which can then be used to inform analyses and possible intervention policies. To illustrate the utility of this approach, we present a simple coupled model of infectious diseases and economic growth, where poverty traps emerge from nonlinear relationships determined by the number of pathogens in the system. These nonlinearities are comparable to those often incorporated into poverty trap models in the economics literature, but, importantly, here the mechanism is anchored in core ecological principles. Coupled models of this sort could be usefully developed in many economically important biophysical systems--such as agriculture, fisheries, nutrition, and land use change--to serve as foundations for deeper explorations of how fundamental ecological processes influence structural poverty and economic development., Competing Interests: The authors have declared that no competing interests exist.

Background: Life-Space Assessment captures community mobility and social participation and quantifies the distance, frequency, and independence obtained as an older adult moves through his or her environment. Reduced estimated glomerular filtration rate (eGFR) is associated with decline in activities of daily living among older adults, but less is known about the association of eGFR with restrictions in mobility., Study Design: Prospective observational cohort study., Setting & Participants: Community-dwelling Medicare beneficiaries from the University of Alabama at Birmingham Study of Aging who had serum creatinine measured during a baseline in-home study visit and completed at least one telephone follow-up (N = 390)., Predictor: eGFR ≥ 60, 45-59, and <45 mL/min/1.73 m(2)., Outcome: Life-space mobility trajectory., Measurements: Life-space mobility was evaluated by telephone every 6 months for up to 4.5 years using the previously validated Life-Space Assessment. Scores using this tool range from 0-120 (higher scores indicate greater mobility)., Results: Mean age of the 390 participants was 77.6 ± 5.8 (SD) years, 41% were African American, 50.5% were women; 30.0% had eGFR of 45-59 mL/min/1.73 m(2), and 20.2% had eGFR < 45 mL/min/1.73 m(2). Age-, race-, and sex-adjusted mean baseline life-space mobility scores were 64.8(95% CI, 62.0-67.6), 63.8 (95% CI, 60.3-67.4), and 58.3 (95% CI, 53.8-62.7) among those with eGFR categories ≥ 60, 45-59, and <45 mL/min/1.73 m(2), respectively. Compared with those with eGFRs ≥ 60 mL/min/1.73 m(2), a more rapid decline in life-space mobility was found among those with eGFRs < 45 mL/min/1.73 m(2), though this did not reach statistical significance (P=0.06); a similar effect was not seen among those with eGFRs of 45-59 mL/min/1.73 m(2) (P=0.3)., Limitations: Urinary albumin or longitudinal measures of eGFR were not available., Conclusions: eGFR < 45 mL/min/1.73 m(2) was associated with a trend toward a more rapid decline in life-space mobility among community-dwelling older adults. Findings should be confirmed in a larger population., (Published by Elsevier Inc.)

Frailty prevalence in older adults has been reported but is largely unknown in middle-aged adults. We determined the prevalence of frailty indicators among middle-aged and older adults from a general Swiss population characterized by universal health insurance coverage and assessed the determinants of frailty with a special focus on socioeconomic status. Participants aged 50 and more from the population-based 2006-2010 Bus Santé study were included (N = 2,930). Four frailty indicators (weakness, shrinking, exhaustion, and low activity) were measured according to standard definitions. Multivariate logistic regressions were used to determine associations. Overall, 63.5%, 28.7%, and 7.8% participants presented no frailty indicators, one frailty indicator, and two or more frailty indicators, respectively. Among middle-aged participants (50-65 years), 75.1%, 22.2%, and 2.7% presented 0, 1, and 2 or more frailty indicators. The number of frailty indicators was positively associated with age, hypertension, and current smoking and negatively associated with male gender, body mass index, waist-to-hip ratio, and serum total cholesterol level. Lower income level but not education was associated with higher number of frailty indicators. Frailty indicators are frequently encountered in both older and middle-aged adults from the Swiss general population. Despite universal health insurance coverage, household income is independently associated with frailty.

Needing assistance with activities of daily living (ADL) is an early indicator of functional decline and has important implications for individuals' quality of life. However, correlates of need for ADL assistance have received limited attention among patients undergoing maintenance hemodialysis (HD). A multicenter cohort of 742 prevalent HD patients was assessed in 2009-2011 and classified as frail, prefrail and nonfrail by the Fried frailty index (recent unintentional weight loss, reported exhaustion, low grip strength, slow walk speed, low physical activity). Patients reported need for assistance with 4 ADL tasks and identified contributing symptoms/conditions (pain, balance, endurance, weakness, others). Nearly 1 in 5 patients needed assistance with 1 or more ADL. Multivariable analysis showed increased odds for needing ADL assistance among frail (odds ratio [OR] 11.35; 95% confidence interval [CI] 5.50-23.41; P < 0.001) and prefrail (OR 1.93; 95% CI 1.01-3.68; P = 0.046) compared with non-frail patients. In addition, the odds for needing ADL assistance were lower among blacks compared with whites and were higher among patients with diabetes, lung disease, and stroke. Balance, weakness, and "other" (frequently dialysis-related) symptoms/conditions were the most frequently named reasons for ADL difficulty. In addition to interventions such as increasing physical activity that might delay or reverse the process of frailty, the immediate symptoms/conditions to which individuals attribute their ADL difficulty may have clinical relevance for developing targeted management and/or treatment approaches., (© 2013 International Society for Hemodialysis.)

Background and Objectives: Apparent treatment-resistant hypertension is defined as systolic/diastolic BP ≥ 140/90 mmHg with concurrent use of three or more antihypertensive medication classes or use of four or more antihypertensive medication classes regardless of BP level., Design, Setting, Participants, & Measurements: The prevalence of apparent treatment-resistant hypertension among Reasons for Geographic and Racial Differences in Stroke study participants treated for hypertension (n=10,700) was determined by level of estimated GFR and albumin-to-creatinine ratio, and correlates of apparent treatment-resistant hypertension among those participants with CKD were evaluated. CKD was defined as an albumin-to-creatinine ratio ≥ 30 mg/g or estimated GFR<60 ml/min per 1.73 m(2)., Results: The prevalence of apparent treatment-resistant hypertension was 15.8%, 24.9%, and 33.4% for those participants with estimated GFR ≥ 60, 45-59, and <45 ml/min per 1.73 m(2), respectively, and 12.1%, 20.8%, 27.7%, and 48.3% for albumin-to-creatinine ratio<10, 10-29, 30-299, and ≥ 300 mg/g, respectively. The multivariable-adjusted prevalence ratios (95% confidence intervals) for apparent treatment-resistant hypertension were 1.25 (1.11 to 1.41) and 1.20 (1.04 to 1.37) for estimated GFR levels of 45-59 and <45 ml/min per 1.73 m(2), respectively, versus ≥ 60 ml/min per 1.73 m(2) and 1.54 (1.39 to 1.71), 1.76 (1.57 to 1.97), and 2.44 (2.12 to 2.81) for albumin-to-creatinine ratio levels of 10-29, 30-299, and ≥ 300 mg/g, respectively, versus albumin-to-creatinine ratio<10 mg/g. After multivariable adjustment, men, black race, larger waist circumference, diabetes, history of myocardial infarction or stroke, statin use, and lower estimated GFR and higher albumin-to-creatinine ratio levels were associated with apparent treatment-resistant hypertension among individuals with CKD., Conclusions: This study highlights the high prevalence of apparent treatment-resistant hypertension among individuals with CKD.

Background: Angiotensin-converting enzyme inhibitors improve outcomes in systolic heart failure (SHF). However, doubts linger about their effect in SHF patients with chronic kidney disease (CKD)., Methods: In the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial, 2569 ambulatory chronic HF patients with left ventricular ejection fraction ≤ 35% and serum creatinine level ≤ 2.5mg/dl were randomized to receive either placebo (n=1284) or enalapril (n=1285). Of the 2502 patients with baseline serum creatinine data, 1036 had CKD (estimated glomerular filtration rate <60 ml/min/1.73 m(2))., Results: Overall, during 35 months of median follow-up, all-cause mortality occurred in 40% (502/1252) and 35% (440/1250) of placebo and enalapril patients, respectively (hazard ratio {HR}, 0.84; 95% confidence interval {CI}, 0.74-0.95; p=0.007). All-cause mortality occurred in 45% and 42% of patients with CKD (HR, 0.88; 95% CI, 0.73-1.06; p=0.164), and 36% and 31% of non-CKD patients (HR, 0.82; 95% CI, 0.69-0.98; p=0.028) in the placebo and enalapril groups, respectively (p for interaction=0.615). Enalapril reduced cardiovascular hospitalization in those with CKD (HR, 0.77; 95% CI, 0.66-0.90; p<0.001) and without CKD (HR, 0.80; 95% CI, 0.70-0.91; p<0.001). Among patients in the enalapril group, serum creatinine elevation was significantly higher in those without CKD (0.09 versus 0.04 mg/dl in CKD; p=0.003) during first year of follow-up, but there was no differences in changes in systolic blood pressure (mean drop, 7 mm Hg, both) and serum potassium (mean increase, 0. /L, both)., Conclusions: Enalapril reduces mortality and hospitalization in SHF patients without significant heterogeneity between those with and without CKD., (Published by Elsevier Ireland Ltd.)

Background: There are few data available on low hemoglobin and incident falls in the general U.S. population., Methods: Of 30,239 black and white U.S. adults ≥45 years in the population-based REasons for Geographic And Racial Differences in Stroke study, 16,782 had hemoglobin measured at baseline and follow-up data on falls. Hemoglobin was categorized by 1.0 g/dL increments relative to the World Health Organization anemia threshold (<13.0 g/dL for men, <12.0 g/dL for women). Recurrent falls (≥2 falls in the 6 months after baseline) were assessed during a telephone interview., Results: Recurrent falls occurred in 3.9% of men and 4.8% of women. Compared with those with a hemoglobin level 1 to 2 g/dL above the anemia cut-off, multivariable adjusted odds ratios (95% confidence intervals) for recurrent falls associated with hemoglobin levels ≥3, 2 to <3 and 0 to 1 g/dL above the cut-off point, and 0 to <1 and ≥1 g/dL below the cut-off point were 0.73 (0.45-1.19), 0.84 (0.57-1.24), 1.29 (0.88-1.90), 1.32 (0.0.80-1.2.18) and 2.12 (1.23-3.63), respectively, among men (linear trend P < 0.001), and 1.59 (1.10-2.3), 1.24 (0.95-1.62), 1.42(1.11-1.81), 1.28 (0.91-1.80) and 1.76 (1.13-2.74), respectively, among women (linear trend P = 0.45; quadratic trend P = 0.016)., Conclusions: Among men, lower hemoglobin levels were associated with an increased risk for recurrent falls. Although our findings suggest an increased risk for recurrent falls at both lower and higher hemoglobin levels among women, these findings should be confirmed in subsequent studies.

Objectives: To evaluate the association between six nondisease-specific problems (problems that cross multiple domains of health) and mortality in middle-aged and older adults., Design: Prospective, observational cohort., Setting: U.S. population sample., Participants: Participants included 23,669 black and white U.S. adults aged 45 and older enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study., Measurements: Nondisease-specific problems included cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy. Age-stratified (<65, 65-74, ≥ 75) hazard ratios for all-cause mortality were calculated for each problem individually and according to number of problems., Results: One or more nondisease-specific problems occurred in 40% of participants younger than 65, 45% of those aged 65 to 74, and 55% of those aged 75 and older. Compared with participants with none of these problems, the multivariable adjusted hazard ratio for all-cause mortality associated with each additional nondisease-specific problem was 1.34 (95% confidence interval (CI) = 1.23-1.46) for participants younger than 65, 1.24 (95% CI = 1.15-1.35) for those aged 65 to 74, and 1.30 (95% CI = 1.21-1.39) for those aged 75 and older., Conclusion: Nondisease-specific problems were associated with mortality across a wide age spectrum. Future studies should explore whether treating these problems will improve survival and identify innovative healthcare models to address multiple nondisease-specific problems simultaneously., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Background: It is not known whether geographic differences in the prevalence of chronic kidney disease exist and are associated with end-stage renal disease (ESRD) incidence rates across the United States., Study Design: Cross-sectional and ecologic., Setting & Participants: White (n = 16,410) and black (n = 11,109) participants from across the continental United States in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study., Predictor: Geographic region, defined by the 18 networks of the US ESRD Network Program., Outcomes & Measurements: Albuminuria, defined as albumin-creatinine ratio ≥30 mg/g, and decreased estimated glomerular filtration rate (eGFR), defined as <60 mL/min/1.73 m(2), were measured in the REGARDS Study. ESRD incidence rates were obtained from the US Renal Data System., Results: For whites, the network-specific prevalence of albuminuria ranged from 8.4% (95% CI, 3.3%-13.5%) in Network 15 to 14.8% (95% CI, 8.0%-21.6%) in Network 3, and decreased eGFR ranged from 4.3% (95% CI, 2.0%-6.6%) in Network 4 to 16.7% (95% CI, 12.7%-20.7%) in Network 7. For blacks, the prevalence of albuminuria ranged from 12.1% (95% CI, 8.7%-15.5%) in Network 5 to 26.5% (95% CI, 16.7%-36.3%) in Network 4, and decreased eGFR ranged from 6.7% (95% CI, 5.0%-8.4%) in Network 17/18 to 13.4% (95% CI, 7.8%-19.1%) in Network 12. Spearman correlation coefficients for the prevalence of albuminuria and decreased eGFR with network-specific ESRD incidence rates were 0.49 and 0.24, respectively, for whites and 0.29 and 0.25, respectively, for blacks., Limitations: There were few cases of albuminuria and decreased eGFR in some geographic regions., Conclusions: In the United States, substantial geographic variations in the prevalence of albuminuria and decreased eGFR exist, but were correlated only modestly with ESRD incidence, suggesting the chronic kidney disease burden may not explain the geographic variation in ESRD incidence., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The National Kidney Foundation (NKF), Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification expanded the focus of chronic kidney disease (CKD) management from end-stage renal disease (ESRD) to the entire spectrum of kidney disease including early kidney damage through the stages of kidney disease to kidney failure. A consequence of these guidelines is that a large number of older adults are being identified as having CKD, many of whom will not progress to ESRD. Concerns have been raised that reduced estimated glomerular filtration rate (eGFR) among older adults may not represent "disease" and using age-specific cut-points for staging CKD has been proposed. This implies that among older adults, CKD, as currently defined, may be benign. Several recent studies have shown that among people greater than or equal to 80 years old, CKD is associated with an increased risk for concurrent complications of CKD (eg, anemia, acidosis) and adverse outcomes including mortality and cardiovascular disease (CVD). Further, among older adults, CKD is associated with problems not traditionally thought to be associated with kidney disease. These nondisease-specific outcomes include functional decline, cognitive impairment, and frailty. Future research studies are necessary to determine the impact of concurrent complications of CKD and nondisease-specific problems on mortality and functional decline, the longitudinal trajectories of CKD progression, and patient preferences among the oldest old with CKD.

Aims: Instrumental activities of daily living (IADLs) are tasks that are necessary for independent community living. These tasks often require intact physical and cognitive function, the impairment of which may adversely affect health in older adults. In the current study, we examined the association between IADL impairment and incident heart failure (HF) in community-dwelling older adults., Methods and Results: Of the 5795 community-dwelling adults, aged ≥65 years, in the Cardiovascular Health Study, 5511 had data on baseline IADL and were free of prevalent HF. Of these, 1333 (24%) had baseline IADL impairment, defined as self-reported difficulty with one or more of the following tasks: using the telephone, preparing food, performing light and heavy housework, managing finances, and shopping. Propensity scores for IADL impairment, estimated for each of the 5511 participants, were used to assemble a cohort of 1038 pairs of participants with and without IADL impairment who were balanced on 42 baseline characteristics. Centrally adjudicated incident HF occurred in 26% and 21% of matched participants with and without IADL impairment, respectively, during >12 years of follow-up [matched hazard ratio (HR) 1.33; 95% confidence interval (CI) 1.11-1.59; P = 0.002]. Unadjusted and multivariable-adjusted HRs for incident HF before matching were 1.77 (95% CI 1.56-2.01; P < 0.001) and 1.33 (95% CI 1.15-1.54; P < 0.001), respectively. IADL impairment was also associated with all-cause mortality (matched HR 1.19; 95% CI 1.06-1.34; P = 0.004)., Conclusion: Among community-dwelling older adults free of baseline HF, IADL impairment is a strong and independent predictor of incident HF and mortality.

The last decade has seen the evolution and ongoing refinement of a disease-oriented approach to chronic kidney disease (CKD). Disease-oriented models of care assume a direct causal association between observed signs and symptoms and underlying disease pathophysiologic processes. Treatment plans target underlying disease mechanisms with the goal of improving disease-related outcomes. Because average glomerular filtrate rates tend to decrease with age, CKD becomes increasingly prevalent with advancing age and those who meet criteria for CKD are disproportionately elderly. However, several features of geriatric populations may limit the utility of disease-oriented models of care. In older adults, complex comorbid conditions and geriatric syndromes are common; signs and symptoms often do not reflect a single underlying pathophysiologic process; there can be substantial heterogeneity in life expectancy, functional status, and health priorities; and information about the safety and efficacy of recommended interventions often is lacking. For all these reasons, geriatricians have tended to favor an individualized patient-centered model of care over more traditional disease-based approaches. An individualized approach prioritizes patient preferences and embraces the notion that observed signs and symptoms often do not reflect a single unifying disease process and instead reflect the complex interplay between many different factors. This approach emphasizes modifiable outcomes that matter to the patient. Prognostic information related to these and other outcomes generally is used to shape rather than dictate treatment decisions. We argue that an individualized patient-centered approach to care may have more to offer than a traditional disease-based approach to CKD in many older adults., (Published by Elsevier Inc.)

Background and Objectives: It has been suggested that moderate reductions in estimated GFR (eGFR) among older adults may not reflect chronic kidney disease (CKD)., Design, Setting, Participants, & Measurements: We examined age-specific (<60, 60 to 69, 70 to 79, and ≥80 years) associations between eGFR level and six concurrent CKD complications among 30,528 participants from the National Health and Nutrition Examination Survey (NHANES) 1988 to 1994 and 1999 to 2006 (n = 8242 from NHANES 2003 to 2006 for hyperparathyroidism). Complications included anemia (hemoglobin <12 g/dl women, <13.5 g/dl men), acidosis (bicarbonate <22 mEq/L), hyperphosphatemia (phosphorus ≥4.5 mg/dl), hypoalbuminemia (albumin <3.5 mg/dl), hyperparathyroidism (intact parathyroid hormone ≥70 pg/ml), and hypertension (systolic/diastolic BP ≥140/90 mmHg or antihypertensive use)., Results: Among participants ≥80 years old, compared with those with estimated GFR (eGFR) ≥60 ml/min per 1.73 m(2), the multivariable adjusted prevalence ratios (95% confidence interval) associated with eGFR levels of 45 to 59 and <45 ml/min per 1.73 m(2) were 1.39 (1.11 to1.73) and 2.06 (1.59 to 2.67) for anemia, 1.33 (0.89 to 1.98) and 2.47 (1.52 to 4.00) for acidosis, 1.11 (0.70 to 1.76) and 2.16 (1.36 to 3.42) for hyperphosphatemia, 2.04 (1.39 to 3.00) and 2.83 (1.76 to 4.53) for hyperparathyroidism and 1.09 (1.03 to 1.14), and 1.12 (1.05 to 1.19) for hypertension, respectively. Higher prevalence ratios for these complications at lower eGFR levels were also present at younger ages. Reduced eGFR was associated with hypoalbuminemia only for adults <70., Conclusions: Reduced eGFR was associated with a higher prevalence of several concurrent CKD complications, regardless of age.

Background and Objectives: It has been suggested that reduced estimated GFR (eGFR) among older adults does not necessarily reflect a pathologic phenomenon., Design, Setting, Participants, & Measurements: We examined the association between eGFR and albumin-to-creatinine ratio (ACR) and all-cause mortality stratified by age (45 to 59.9, 60 to 69.9, 70 to 79.9, and ≥80 years) among 24,350 U.S. adults in the population-based REasons for Geographic and Racial Differences in Stroke (REGARDS) study. A spot urine sample was used to calculate ACR, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to calculate eGFR. All-cause mortality was assessed over a median follow-up of 4.5 years., Results: Among participants ≥80 years of age (n = 1669), the age, race, gender, and geographic region of residence adjusted hazard ratios (95% confidence intervals) for mortality associated with eGFR levels of 45 to 59.9 and <45 ml/min per 1.73 m(2), versus ≥60 ml/min per 1.73 m(2), were 1.6 (1.3 - 2.1) and 2.2 (1.7 - 2.9), respectively. Also, among participants ≥80 years of age, the hazard ratios for mortality associated with ACR levels of 10 to 29.9, 30 to 299.9, and ≥300 mg/g, versus <10 mg/g, were 1.7 (1.3 - 2.1), 2.5 (1.9 - 3.3), and 5.1 (3.6 - 7.4), respectively. These associations were present after further multivariable adjustment and within the younger age groupings studied., Conclusions: These data suggest that reduced eGFR and albuminuria confer an increased risk for mortality in all age groups, including adults ≥80 years of age.

The harvest of wildlife for human consumption is valued at several billion dollars annually and provides an essential source of meat for hundreds of millions of rural people living in poverty. This harvest is also considered among the greatest threats to biodiversity throughout Africa, Asia, and Latin America. Economic development is often proposed as an essential first step to win-win solutions for poverty alleviation and biodiversity conservation by breaking rural reliance on wildlife. However, increases in wealth may accelerate consumption and extend the scale and efficiency of wildlife harvest. Our ability to assess the likelihood of these two contrasting outcomes and to design approaches that simultaneously consider poverty and biodiversity loss is impeded by a weak understanding of the direction and shape of their interaction. Here, we present results of economic and wildlife use surveys conducted in 2,000 households from 96 settlements in Ghana, Cameroon, Tanzania, and Madagascar. We examine the individual and interactive roles of wealth, relative food prices, market access, and opportunity costs of time spent hunting on household rates of wildlife consumption. Despite great differences in biogeographic, social, and economic aspects of our study sites, we found a consistent relationship between wealth and wildlife consumption. Wealthier households consume more bushmeat in settlements nearer urban areas, but the opposite pattern is observed in more isolated settlements. Wildlife hunting and consumption increase when alternative livelihoods collapse, but this safety net is an option only for those people living near harvestable wildlife.

This study explores the potential of index insurance as a mechanism to finance community-based biodiversity conservation in areas where a strong correlation exists between natural disaster risk, keystone species populations, and the well-being of the local population. We illustrate this potential using the case of hornbill conservation in the Budo-Sungai Padi rainforests of southern Thailand, using 16-y hornbill reproduction data and 5-y household expenditures data reflecting local economic well-being. We show that severe windstorms cause both lower household expenditures and critical nest tree losses that directly constrain nesting capacity and so reduce the number of hornbill chicks recruited in the following breeding season. Forest residents' coping strategies further disturb hornbills and their forest habitats, compounding windstorms' adverse effects on hornbills' recruitment in the following year. The strong statistical relationship between wind speed and both hornbill nest tree losses and household expenditures opens up an opportunity to design wind-based index insurance contracts that could both enhance hornbill conservation and support disaster-affected households in the region. We demonstrate how such contracts could be written and operationalized and then use simulations to show the significant promise of unique insurance-based approaches to address weather-related risk that threatens both biodiversity and poor populations.

This paper introduces a special feature on biodiversity conservation and poverty traps. We define and explain the core concepts and then identify four distinct classes of mechanisms that define important interlinkages between biodiversity and poverty. The multiplicity of candidate mechanisms underscores a major challenge in designing policy appropriate across settings. This framework is then used to introduce the ensuing set of papers, which empirically explore these various mechanisms linking poverty traps and biodiversity conservation.

Background: Although chronic kidney disease (CKD) is associated with poor physical function, less is known about the longitudinal association between CKD and the decline of instrumental activities of daily living (IADL) and basic activities of daily living (BADL) among community-dwelling older adults., Methods: Participants were part of the prospective observational University of Alabama at Birmingham Study of Aging (n = 357). CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) using the Modification of Diet in Renal Disease equation. Primary outcomes were IADL and BADL decline defined as an increase in the number of activities for which participants reported difficulty after 2 years. Forward stepwise logistic regression was used to determine associations of baseline CKD and functional decline., Results: Participants had a mean age of 77.4 (SD = 5.8) years, 41% were African American, and 52% women. IADL decline occurred in 35% of those with CKD and 17% of those without (unadjusted odds ratio, 2.62, 95% confidence intervals [95% CI], 1.59-4.30, p < .001). BADL decline occurred in 20% and 7% of those with and without CKD, respectively (unadjusted odds ratio, 3.37; 95% CI, 1.73-6.57; p < .001). Multivariable-adjusted odds ratio's (95% CI's) for CKD-associated IADL and BADL decline were 1.83 (1.06-3.17, p =.030) and 2.46 (1.19-5.12, p = .016), respectively. CKD Stage ≥3B (estimated glomerular filtration rate <45 mL/min/1.73 m(2)) was associated with higher multivariable-adjusted odds of both IADL (3.12, 95% CI, 1.38-7.06, p = .006) and BADL (3.78, 95% CI, 1.36-9.77, p = .006) decline., Conclusion: In community-dwelling older adults, CKD is associated with IADL and BADL decline.

Objective: To compare the prevalence of blastocyst development and euploidy in XX versus XY embryos., Design: Retrospective cohort study., Setting: Boston IVF, a large university-affiliated reproductive medicine practice., Patient(s): All patients who underwent their first preimplantation genetic screening cycle between January 1, 2006, and December 31, 2007., Intervention(s): In vitro fertilization and preimplantation genetic screening., Main Outcome Measure(s): Proportion of embryos that developed to the blastocyst stage by day 5 and prevalence of euploidy for chromosomes 8, 13, 14, 15, 16, 17, 18, 20, 21, and 22 in XX versus XY embryos., Result(s): Seven hundred fifty-eight embryos from 138 cycles in 138 patients were analyzed. Three hundred sixty-six (48%) were XX, and 392 (52%) were XY. XX and XY embryos were equally likely to develop to the blastocyst stage by day 5 and were equally likely to be euploid for the analyzed chromosomes., Conclusion(s): Our data suggest that extending embryo culture to day 5 does not lead to sex selection and that euploidy and aneuploidy are not sex dependent., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The relationship between stage of chronic kidney disease (CKD) and incident heart failure (HF) remains unclear., Methods: Of the 5,795 community-dwelling adults ≥65 years in the Cardiovascular Health Study, 5,450 were free of prevalent HF and had baseline estimated glomerular filtration rate (eGFR: ml/min/1.73 m(2)) data. Of these, 898 (16%) had CKD 3A (eGFR 45-59 ml/min/1.73 m(2)) and 242 (4%) had CKD stage ≥3B (eGFR <45 ml/min/1.73 m(2)). Data on baseline proteinuria were not available and 4,310 (79%) individuals with eGFR ≥60 ml/min/1.73 m(2) were considered to have no CKD. Propensity scores estimated separately for CKD 3A and ≥3B were used to assemble two cohorts of 1,714 (857 pairs with CKD 3A and no CKD) and 557 participants (148 CKD ≥3B and 409 no CKD), respectively, balanced on 50 baseline characteristics., Results: During 13 years of follow-up, centrally-adjudicated incident HF occurred in 19, 24 and 38% of pre-match participants without CKD (reference), with CKD 3A [unadjusted hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.20-1.63; p < 0.001] and with CKD ≥3B (HR 3.37; 95% CI 2.71-4.18; p < 0.001), respectively. In contrast, among matched participants, incident HF occurred in 23 and 23% of those with CKD 3A and no CKD, respectively (HR 1.03; 95% CI 0.85-1.26; p = 0.746), and 36 and 28% of those with CKD ≥3B and no CKD, respectively (HR 1.44; 95% CI 1.04-2.00; p = 0.027)., Conclusions: Among community-dwelling older adults, CKD is a marker of incident HF regardless of stage; however, CKD ≥3B, not CKD 3A, has a modest independent association with incident HF., (Copyright © 2011 S. Karger AG, Basel.)

The growing literature on poverty traps emphasizes the links between multiple equilibria and risk avoidance. However, multiple equilibria may also foster risk-taking behavior by some poor people. We illustrate this idea with a simple analytical model in which people with different wealth and ability endowments make investment and risky activity choices in the presence of known nonconvex asset dynamics. This model underscores a crucial distinction between familiar static concepts of risk aversion and forward-looking dynamic risk responses to nonconvex asset dynamics. Even when unobservable preferences exhibit decreasing absolute risk aversion, observed behavior may suggest that risk aversion actually increases with wealth near perceived dynamic asset thresholds. Although high ability individuals are not immune from poverty traps, they can leverage their capital endowments more effectively than lower ability types and are therefore less likely to take seemingly excessive risks. In general, linkages between behavioral responses and wealth dynamics often seem to run in both directions. Both theoretical and empirical poverty trap research could benefit from making this two-way linkage more explicit.