Search

Background: Stretching improves range of motion and changes the viscoelastic properties of muscle-tendon units. We hypothesized that a regular stretching program would reduce the functional consequences of pain for employees working in echocardiographic, ultrasound, and interventional laboratories. This exploratory, proof-of-concept study was meant to inform expectations for future randomized, controlled studies., Methods: In this unblinded, nonrandomized, observational study, we enrolled 196 health care professionals working in the interventional and echocardiographic laboratories in the departments of cardiology and radiology at Mayo Clinic and Mayo Clinic Health System to perform 15-minute neck, upper extremity, low back, and lower extremity stretches for 1 year. The functional consequences of pain were self-reported by using the Disability of Arm, Shoulder, and Hand; Neck Disability Index; and Roland-Morris Questionnaire, which was administered at baseline and at 1 year to measure response to stretching. Monitoring with an assessment plan for injuries was undertaken. Employees who were pregnant, unable to do exercises, or under active orthopedic treatment, were excluded., Results: Of the 196 enrolled, 68 (35%) provided complete data at both baseline and follow-up. The majority of participants were over 40 years (n = 51; 72%) and female (n = 51; 72%). Participants performed stretches for 120.5 (IQR, 52-184) days over the year. The number of days of doing the stretches was well distributed across the study period with median quarters 1, 2, 3, and 4 of 32 (19-51), 32 (20-51), 31 (17-45), and 32.5 (12-47) days, respectively. The majority of participants (52.3%) stretched before, 18.9% stretched during and 28.8% stretched after work. Self-reported upper extremity disability improved in the treatment group with a significant decrease in the median Disability of Arm, Shoulder, and Hand score (5.2 to 2.6; P = .002). There was an absolute 4% decrease in the Neck Disability Index score, between baseline and 1-year follow-up (10% to 6%, P = .017). There was not a significant change in the Roland-Morris Questionnaire from baseline to follow-up (1 to 0; P = .287). No participant reported any stretch-related injuries., Conclusions: A routine stretching program may represent an attractive, low-cost, noninvasive option to reduce upper extremity musculoskeletal disability of employees working in the echocardiographic, ultrasound, and interventional laboratories. Larger randomized trials are needed to confirm the association., (© 2024 The Author(s).)

Excursion of the median nerve and the surrounding subsynovial connective tissue (SSCT) is diminished in patients with carpal tunnel syndrome (CTS). This study sought to determine if SSCT excursion could be utilized to predict surgical outcome. Idiopathic CTS patients were reviewed with ultrasound and electrodiagnostic tests at baseline. A speckle tracking algorithm was used to determine SSCT relative to tendon motion (shear index). Analysis of variance tests were used to compare SSCT motion with disease severity at baseline. Adjusted linear regressions were used to test the association with patient-reported outcome. A total of 90 CTS patients were analyzed and found to have an average shear index of 79% (95% confidence interval: 76.3%-81.6%). SSCT motion was lower in CTS patients with increasing electrophysiological severity (p = 0.0475). There was no significant association of pre-operative SSCT motion with symptomatic improvement (p = 0.268). Overall, SSCT motion is decreased in CTS patients, but exhibits limited correlation with clinical severity., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Rationale & Objective: Clinical practice guidelines for dietary intake in hemodialysis focus on individual nutrients. Little is known about associations of dietary patterns with survival. We evaluated the associations of dietary patterns with cardiovascular and all-cause mortality among adults treated by hemodialysis., Study Design: Prospective cohort study., Setting & Participants: 8,110 of 9,757 consecutive adults on hemodialysis (January 2014 to June 2017) treated in a multinational private dialysis network and with analyzable dietary data., Exposures: Data-driven dietary patterns based on the GA 2 LEN food frequency questionnaire. Participants received a score for each identified pattern, with higher scores indicating closer resemblance of their diet to the identified pattern. Quartiles of standardized pattern scores were used as primary exposures., Outcomes: Cardiovascular and all-cause mortality., Analytical Approach: Principal components analysis with varimax rotation to identify common dietary patterns. Adjusted proportional hazards regression analyses with country as a random effect to estimate the associations between dietary pattern scores and mortality. Associations were expressed as adjusted HRs with 95% CIs, using the lowest quartile score as reference., Results: During a median follow-up of 2.7 years (18,666 person-years), there were 2,087 deaths (958 cardiovascular). 2 dietary patterns, "fruit and vegetable" and "Western," were identified. For the fruit and vegetable dietary pattern score, adjusted HRs, in ascending quartiles, were 0.94 (95% CI, 0.76-1.15), 0.83 (95% CI, 0.66-1.06), and 0.91 (95% CI, 0.69-1.21) for cardiovascular mortality and 0.95 (95% CI, 0.83-1.09), 0.84 (95% CI, 0.71-0.99), and 0.87 (95% CI, 0.72-1.05) for all-cause mortality. For the Western dietary pattern score, the corresponding estimates were 1.10 (95% CI, 0.90-1.35), 1.11 (95% CI, 0.87-1.41), and 1.09 (95% CI, 0.80-1.49) for cardiovascular mortality and 1.01 (95% CI, 0.88-1.16), 1.00 (95% CI, 0.85-1.18), and 1.14 (95% CI, 0.93-1.41) for all-cause mortality., Limitations: Self-reported food frequency questionnaire, data-driven approach., Conclusions: These findings did not confirm an association between mortality among patients receiving long-term hemodialysis and the extent to which dietary patterns were either high in fruit and vegetables or consistent with a Western diet., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm 2 and decreased to 13.3 ± 3.8 mm 2 (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (β = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (β = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome., (Copyright © 2019 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

The concepts associated with work disability are not identical to those associated with medical disability. In addition to a worker's medical condition, the resultant functional limitations, and loss of participation in society, the injured or ill worker must often navigate a complex administrative system that often seems adversarial. This process is made less adversarial with the willingness to participate of knowledgeable clinicians. This article informs the interested clinician in regard to the unique aspects of work disability, including the issues of work accommodations, restrictions, and fitness for duty; prolonged work disability; and other return-to-work considerations at maximum medical improvement., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Chronic kidney disease is a risk factor for oral diseases, which may be associated with premature death. We evaluated the risk of all-cause and cardiovascular mortality associated with oral mucosal lesions in adults with kidney failure treated with long-term haemodialysis., Methods: Oral mucosal lesions (herpes, ulceration, neoformation, white lesion, red lesion, oral candidiasis, geographical tongue, petechial lesions, and fissured tongue) were evaluated within the Oral Diseases in Haemodialysis (ORAL-D) study, a multinational cohort study of 4726 haemodialysis adults. We conducted cox regression analyses adjusted for demographic and clinical variables to evaluate the association with all-cause and cardiovascular mortality., Results: Overall, 4205 adults (mean age 61.6 ± 15.6 years) underwent oral mucosal examination with 40% affected by at least one lesion. The prevalence of oral lesions was (in order of frequency): oral herpes 0.5%, mucosal ulceration 1.7%, neoformation 2.0%, white lesion 3.5%, red lesion 4.0%, oral candidiasis 4.6%, geographical tongue 4.9%, petechial lesions 7.9%, and fissured tongue 10.7%. During median follow-up of 3.5 years, 2114 patients died (1013 due to cardiovascular disease). No association was observed between any individual oral lesion and all-cause or cardiovascular mortality when adjusted for comorbidities, except for oral candidiasis, which was associated with all-cause mortality (adjusted hazard ratio 1.37, 95% CI 1.00 to 1.86) and cardiovascular mortality (adjusted hazard ratio 1.64, 95% CI 1.09 to 2.46)., Conclusion: Oral mucosal lesions are prevalent in haemodialysis patients. Oral candidiasis appears to be a risk factor for death due to cardiovascular diseases., Competing Interests: MR, PN, VS, EC, RG, MRL, MT, PS, AB-S, JD, LF, JNF, DC, SS, AGB, JH, CW, LG are employees of Diaverum. GS holds a consultancy with Diaverum Renal Services. JH and GS received unrestricted funding from Diaverum Renal Services, a provider of renal services and LCO (Le Cliniche Odontoiatriche, Italy). Funding was used to assist with the cost of oral examination visits in countries where these required specific funding. Funding was also applied to cover overhead costs for study coordinators in each contributing country, material printing and distribution and procurement of standardized examination kits for all patient assessments. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background and Objectives: Higher fruit and vegetable intake is associated with lower cardiovascular and all-cause mortality in the general population. It is unclear whether this association occurs in patients on hemodialysis, in whom high fruit and vegetable intake is generally discouraged because of a potential risk of hyperkalemia. We aimed to evaluate the association between fruit and vegetable intake and mortality in hemodialysis., Design, Setting, Participants, & Measurements: Fruit and vegetable intake was ascertained by the Global Allergy and Asthma European Network food frequency questionnaire within the Dietary Intake, Death and Hospitalization in Adults with ESKD Treated with Hemodialysis study, a multinational cohort study of 9757 adults on hemodialysis, of whom 8078 (83%) had analyzable dietary data. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association between tertiles of fruit and vegetable intake with all-cause, cardiovascular, and noncardiovascular mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs)., Results: During a median follow up of 2.7 years (18,586 person-years), there were 2082 deaths (954 cardiovascular). The median (interquartile range) number of servings of fruit and vegetables was 8 (4-14) per week; only 4% of the study population consumed at least four servings per day as recommended in the general population. Compared with the lowest tertile of servings per week (0-5.5, median 2), the adjusted hazard ratios for the middle (5.6-10, median 8) and highest (>10, median 17) tertiles were 0.90 (95% CI, 0.81 to 1.00) and 0.80 (95% CI, 0.71 to 0.91) for all-cause mortality, 0.88 (95% CI, 0.76 to 1.02) and 0.77 (95% CI, 0.66 to 0.91) for noncardiovascular mortality and 0.95 (95% CI, 0.81 to 1.11) and 0.84 (95% CI, 0.70 to 1.00) for cardiovascular mortality, respectively., Conclusions: Fruit and vegetable intake in the hemodialysis population is low and a higher consumption is associated with lower all-cause and noncardiovascular death., (Copyright © 2019 by the American Society of Nephrology.)

Background & Aims: Patients on hemodialysis suffer from high risk of premature death, which is largely attributed to cardiovascular disease, but interventions targeting traditional cardiovascular risk factors have made little or no difference. Long chain n-3 polyunsaturated fatty acids (n-3 PUFA) are putative candidates to reduce cardiovascular disease. Diets rich in n-3 PUFA are recommended in the general population, although their role in the hemodialysis setting is uncertain. We evaluated the association between the dietary intake of n-3 PUFA and mortality for hemodialysis patients., Methods: The DIET-HD study is a prospective cohort study (January 2014-June 2017) in 9757 adults treated with hemodialysis in Europe and South America. Dietary n-3 PUFA intake was measured at baseline using the GA 2 LEN Food Frequency Questionnaire. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association of dietary n-3 PUFA intake with cardiovascular and all-cause mortality., Results: During a median follow up of 2.7 years (18,666 person-years), 2087 deaths were recorded, including 829 attributable to cardiovascular causes. One third of the study participants consumed sufficient (at least 1.75 g/week) n-3 PUFA recommended for primary cardiovascular prevention, and less than 10% recommended for secondary prevention (7-14 g/week). Compared to patients with the lowest tertile of dietary n-3 PUFA intake (<0.37 g/week), the adjusted hazard ratios (95% confidence interval) for cardiovascular mortality for patients in the middle (0.37 to <1.8 g/week) and highest (≥1.8 g/week) tertiles of n-3 PUFA were 0.82 (0.69-0.98) and 1.03 (0.84-1.26), respectively. Corresponding adjusted hazard ratios for all-cause mortality were 0.96 (0.86-1.08) and 1.00 (0.88-1.13), respectively., Conclusions: Dietary n-3 PUFA intake was not associated with cardiovascular or all-cause mortality in patients on hemodialysis. As dietary n-3 PUFA intake was low, the possibility that n-3 PUFA supplementation might mitigate cardiovascular risk has not been excluded., (Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets associate with lower cardiovascular and all-cause mortality in the general population, but the benefits for patients on hemodialysis are uncertain. Methods Mediterranean and DASH diet scores were derived from the GA 2 LEN Food Frequency Questionnaire within the DIET-HD Study, a multinational cohort study of 9757 adults on hemodialysis. We conducted adjusted Cox regression analyses clustered by country to evaluate the association between diet score tertiles and all-cause and cardiovascular mortality (the lowest tertile was the reference category). Results During the median 2.7-year follow-up, 2087 deaths (829 cardiovascular deaths) occurred. The adjusted hazard ratios (95% confidence intervals) for the middle and highest Mediterranean diet score tertiles were 1.20 (1.01 to 1.41) and 1.14 (0.90 to 1.43), respectively, for cardiovascular mortality and 1.10 (0.99 to 1.22) and 1.01 (0.88 to 1.17), respectively, for all-cause mortality. Corresponding estimates for the same DASH diet score tertiles were 1.01 (0.85 to 1.21) and 1.19 (0.99 to 1.43), respectively, for cardiovascular mortality and 1.03 (0.92 to 1.15) and 1.00 (0.89 to 1.12), respectively, for all-cause mortality. The association between DASH diet score and all-cause death was modified by age ( P =0.03); adjusted hazard ratios for the middle and highest DASH diet score tertiles were 1.02 (0.81 to 1.29) and 0.70 (0.53 to 0.94), respectively, for younger patients (≤60 years old) and 1.05 (0.93 to 1.19) and 1.08 (0.95 to 1.23), respectively, for older patients. Conclusions Mediterranean and DASH diets did not associate with cardiovascular or total mortality in hemodialysis., (Copyright © 2018 by the American Society of Nephrology.)

Purpose: The optimal volume and dose of corticosteroid injections for treatment of carpal tunnel syndrome (CTS) have not yet been established. It is unknown whether the volume of injectate influences the outcome of carpal tunnel injection. The purpose of this study was to assess whether there is an association between the volume of injectate and subsequent intervention in the treatment of CTS., Methods: This study evaluated residents of Olmsted County, MN, who were treated with a corticosteroid injection for CTS between 2001 and 2010. Failure of treatment was the primary outcome, defined as a subsequent intervention: either a second injection or carpal tunnel release within 1 year of initial injection. General estimating equations logistic regression was used to assess the association between injectate volume and rate of treatment failure, adjusting for age, sex, effective dose of steroid, type of steroid injected, electrodiagnostic severity, and the presence of comorbidities such as rheumatoid arthritis, diabetes mellitus, peripheral neuropathy, and radiculopathy., Results: There were 856 affected hands in 651 patients. A total of 56% (n = 484) of treated hands received subsequent treatment within 1 year. Multivariable analysis showed that a larger injectate volume was significantly associated with reduced rate of treatment failure within 1 year. Rheumatoid arthritis and ultrasound-guided procedures were also associated with a reduced rate of treatment failure, whereas severe electrodiagnostic results were associated with an increased rate of failure., Conclusions: This study showed that a larger volume of corticosteroid injection is associated with reduced odds of subsequent intervention after a single corticosteroid injection in CTS. Further research is needed to determine the optimal volume for steroid injections in the treatment of CTS., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Corticosteroid injection is a recommended treatment option for carpal tunnel syndrome, before considering surgery. Nevertheless, injections remain controversial because there is strong evidence of only short-term benefits. This study aimed to determine the reintervention rate and to identify prognostic indicators for subsequent treatment after corticosteroid injection for carpal tunnel syndrome., Methods: This study evaluated residents of Olmsted County treated with a corticosteroid injection for carpal tunnel syndrome between 2001 and 2010. Treatment failure was the primary outcome of interest. Two definitions for failure were examined: (1) the patient receiving subsequent procedural intervention and (2) the patient undergoing carpal tunnel release. Survival was estimated using Kaplan-Meier methods, and association of covariates with increased failure was modeled using Cox proportional hazards regression., Results: The study included 774 affected hands in 595 patients. The median follow-up period was 7.4 years. Reintervention was performed in 68 percent of cases, of which 63 percent resulted in eventual surgery. Injectate volume was significant for the outcome of any retreatment [hazard ratio, 0.879 (95 percent CI, 0.804 to 0.96)] and surgery [hazard ratio, 0.906 (95 percent CI, 0.827 to 0.99)]. Rheumatoid arthritis was also significant in both models, with a hazard ratio of 0.627 (95 percent CI, 0.404 to 0.97) for any retreatment and 0.493 (95 percent CI, 0.292 to 0.83) for surgery., Conclusions: In this cohort, 32 percent of patients did not receive subsequent treatment after a single injection, which indicates that there is a therapeutic role for corticosteroid injections in treating carpal tunnel syndrome. Further research is necessary to identify those patients who will benefit from an injection, to provide more individually tailored treatment., Clinical Question/level of Evidence: Risk, III.

Objective: To compare the effectiveness of ultrasound-guided injections to blind injections in the treatment of carpal tunnel syndrome (CTS) in a large community-based cohort., Methods: This study evaluated residents of Olmsted County, Minnesota, treated with a corticosteroid injection for CTS between 2001 and 2010. The proportion of patients receiving retreatment and the duration of retreatment-free survival between blind and ultrasound-guided injections were compared. Propensity score matching was used to control for confounding by indication., Results: In the matched data set consisting of 234 (of 600) hands treated with a blind injection and 87 (of 89) ultrasound-guided injection cases, ultrasound guidance was associated with a reduced hazard of retreatment (hazard ratio 0.59 [95% confidence interval (95% CI) 0.37-0.93]). In addition, ultrasound guidance was associated with 55% reduced odds of retreatment within 1 year compared to blind injections (adjusted odds ratio 0.45 [95% CI 0.24-0.83])., Conclusion: This study indicates that ultrasound-guided injections are more effective in comparison to blind injections in the treatment of CTS., (© 2016, American College of Rheumatology.)

Sexual dysfunction may affect 80% of women in hemodialysis. However the specific patterns and clinical correlates of sexual functioning remain poorly described. The aim of this study was to assess prevalence and correlates of the individual domains of sexual functioning in women treated with hemodialysis. We recruited, into this multinational cross-sectional study, women treated with long-term hemodialysis (Collaborative Working Group on Depression and Sexual dysfunction in Hemodialysis study). Self-reported domains of sexual functioning were assessed by the Female Sexual Function Index, which is routinely administered within the network of dialysis patients followed by the working group. Lower scores represented lower sexual functioning. Socio-demographic and clinical correlates of each domain of sexual functioning were identified by stepwise multivariable linear regression. Sensitivity analyses were restricted to women who reported being sexually active. We found that of 1309 enrolled women, 659 (50.3%) provided complete responses to FSFI survey questions and 232 (35%) reported being sexually active. Overall, most respondents reported either no sexual activity or low sexual functioning in all measured domains (orgasm 75.1%; arousal 64.0%; lubrication 63.3%; pain 60.7%; satisfaction 60.1%; sexual desire 58.0%). Respondents who were waitlisted for a kidney transplant reported scores with higher sexual functioning, while older respondents reported scores with lower functioning. The presence of depression was associated with worse lubrication and pain scores [mean difference for depressed versus non-depressed women (95% CI) -0.42 (-0.73 to -0.11), -0.53 (-0.89 to -0.16), respectively] while women who had experienced a previous cardiovascular event reported higher pain scores [-0.77 (-1.40- to -0.13)]. In conclusion, women in hemodialysis reported scores consistent with marked low sexual functioning across a range of domains; the low functioning appeared to be associated with comorbidity.

Background: Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure., Methods: ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries., Results: Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death., Conclusion: In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis.

Background: Oral disease is a potentially treatable determinant of mortality and quality of life. No comprehensive multinational study to quantify oral disease burden and to identify candidate preventative strategies has been performed in the dialysis setting., Methods: The ORAL disease in hemoDialysis (ORALD) study was a prospective study in adults treated with hemodialysis in Europe (France, Hungary, Italy, Poland, Portugal and Spain) and Argentina. Oral disease was assessed using standardized WHO methods. Participants self-reported oral health practices and symptoms. Sociodemographic and clinical factors associated with oral diseases were determined and assessed within nation states., Results: Of 4726 eligible adults, 4205 (88.9%) participated. Overall, 20.6% were edentulous [95% confidence interval (CI), 19.4-21.8]. Participants had on average 22 (95% CI 21.7-22.2) decayed, missing or filled teeth, while moderate to severe periodontitis affected 40.6% (95% CI 38.9-42.3). Oral disease patterns varied markedly across countries, independent of participant demographics, comorbidity and health practices. Participants in Spain, Poland, Italy and Hungary had the highest mean adjusted odds of edentulousness (2.31, 1.90, 1.90 and 1.54, respectively), while those in Poland, Hungary, Spain and Argentina had the highest odds of ≥14 decayed, missing or filled teeth (23.2, 12.5, 8.14 and 5.23, respectively). Compared with Argentina, adjusted odds ratios for periodontitis were 58.8, 58.3, 27.7, 12.1 and 6.30 for Portugal, Italy, Hungary, France and Poland, respectively. National levels of tobacco consumption, diabetes and child poverty were associated with edentulousness within countries., Conclusions: Oral disease in adults on hemodialysis is very common, frequently severe and highly variable among countries, with much of the variability unexplained by participant characteristics or healthcare. Given the national variation and high burden of disease, strategies to improve oral health in hemodialysis patients will require implementation at a country level rather than at the level of individuals., (© The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: Dental disease is more extensive in adults with chronic kidney disease, but whether dental health and behaviors are associated with survival in the setting of hemodialysis is unknown., Study Design: Prospective multinational cohort., Setting & Participants: 4,205 adults treated with long-term hemodialysis, 2010 to 2012 (Oral Diseases in Hemodialysis [ORAL-D] Study)., Predictors: Dental health as assessed by a standardized dental examination using World Health Organization guidelines and personal oral care, including edentulousness; decayed, missing, and filled teeth index; teeth brushing and flossing; and dental health consultation., Outcomes: All-cause and cardiovascular mortality at 12 months after dental assessment., Measurements: Multivariable-adjusted Cox proportional hazards regression models fitted with shared frailty to account for clustering of mortality risk within countries., Results: During a mean follow-up of 22.1 months, 942 deaths occurred, including 477 cardiovascular deaths. Edentulousness (adjusted HR, 1.29; 95% CI, 1.10-1.51) and decayed, missing, or filled teeth score ≥ 14 (adjusted HR, 1.70; 95% CI, 1.33-2.17) were associated with early all-cause mortality, while dental flossing, using mouthwash, brushing teeth daily, spending at least 2 minutes on oral hygiene daily, changing a toothbrush at least every 3 months, and visiting a dentist within the past 6 months (adjusted HRs of 0.52 [95% CI, 0.32-0.85], 0.79 [95% CI, 0.64-0.97], 0.76 [95% CI, 0.58-0.99], 0.84 [95% CI, 0.71-0.99], 0.79 [95% CI, 0.65-0.95], and 0.79 [95% CI, 0.65-0.96], respectively) were associated with better survival. Results for cardiovascular mortality were similar., Limitations: Convenience sample of clinics., Conclusions: In adults treated with hemodialysis, poorer dental health was associated with early death, whereas preventive dental health practices were associated with longer survival., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Adults with end-stage kidney disease (ESKD) treated with haemodialysis experience mortality of between 15% and 20% each year. Effective interventions that improve health outcomes for long-term dialysis patients remain unproven. Novel and testable determinants of health in dialysis are needed. Nutrition and dietary patterns are potential factors influencing health in other health settings that warrant exploration in multinational studies in men and women treated with dialysis. We report the protocol of the "DIETary intake, death and hospitalisation in adults with end-stage kidney disease treated with HaemoDialysis (DIET-HD) study," a multinational prospective cohort study. DIET-HD will describe associations of nutrition and dietary patterns with major health outcomes for adults treated with dialysis in several countries., Methods and Analysis: DIET-HD will recruit approximately 10,000 adults who have ESKD treated by clinics administered by a single dialysis provider in Argentina, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Spain, Sweden and Turkey. Recruitment will take place between March 2014 and June 2015. The study has currently recruited 8000 participants who have completed baseline data. Nutritional intake and dietary patterns will be measured using the Global Allergy and Asthma European Network (GA(2)LEN) food frequency questionnaire. The primary dietary exposures will be n-3 and n-6 polyunsaturated fatty acid consumption. The primary outcome will be cardiovascular mortality and secondary outcomes will be all-cause mortality, infection-related mortality and hospitalisation., Ethics and Dissemination: The study is approved by the relevant Ethics Committees in participating countries. All participants will provide written informed consent and be free to withdraw their data at any time. The findings of the study will be disseminated through peer-reviewed journals, conference presentations and to participants via regular newsletters. We expect that the DIET-HD study will inform large pragmatic trials of nutrition or dietary interventions in the setting of advanced kidney disease., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To evaluate patient experiences of specific aspects of haemodialysis care across several countries., Design: Cross-sectional survey using the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) questionnaire., Setting: Haemodialysis clinics within a single provider in Europe and South America., Participants: 2748 adults treated in haemodialysis., Primary and Secondary Outcomes: The primary outcome was patient satisfaction with overall care. Secondary outcomes included patient experiences of individual aspects of dialysis care., Results: 2145 (78.1%) adults responded to the questionnaire. Fewer than half (46.5% (95% CI 44.5% to 48.6%)) rated their overall care as excellent. Global perceptions of care were uninfluenced by most respondent characteristics except age and depressive symptoms; older respondents were less critical of their care (adjusted OR for excellent rating 1.44 (1.01 to 2.04)) and those with depressive symptoms were less satisfied (0.56 (0.44 to 0.71)). Aspects of care that respondents most frequently ranked as excellent were staff attention to dialysis vascular access (54% (52% to 56%)); caring of nurses (53% (51% to 55%)); staff responsiveness to pain or discomfort (51% (49% to 53%)); caring, helpfulness and sensitivity of dialysis staff (50% (48% to 52%)); and ease of reaching dialysis staff by telephone (48% (46% to 50%)). The aspects of care least frequently ranked as excellent were information provided when choosing a dialysis modality (23% (21% to 25%)), ease of seeing a social worker (28% (24% to 32%)), information provided about dialysis (34% (32% to 36%)), accuracy of information from nephrologist (eg, about prognosis or likelihood of a kidney transplant; 37% (35% to 39%)) and accuracy of nephrologists' instructions (39% (36% to 41%))., Conclusions: Haemodialysis patients are least satisfied with the complex aspects of care. Patients' expectations for accurate information, prognosis, the likelihood of kidney transplantation and their options when choosing dialysis treatment need to be considered when planning healthcare research and practices., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To describe and review autonomic complications of lightning strike., Methods: Case report and laboratory data including autonomic function tests in a subject who was struck by lightning., Results: A 24-year-old man was struck by lightning. Following that, he developed dysautonomia, with persistent inappropriate sinus tachycardia and autonomic storms, as well as posttraumatic stress disorder (PTSD) and functional neurologic problems., Interpretation: The combination of persistent sinus tachycardia and episodic exacerbations associated with hypertension, diaphoresis, and agitation was highly suggestive of a central hyperadrenergic state with superimposed autonomic storms. Whether the additional PTSD and functional neurologic deficits were due to a direct effect of the lightning strike on the central nervous system or a secondary response is open to speculation.

Background: People with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated. Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required., Methods/design: The ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022., Discussion: This large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

Background and Objectives: The few existing studies of sexual dysfunction in women on hemodialysis are limited by small sample size. This large, cross-sectional study evaluated the prevalence and correlates of female sexual dysfunction in advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, METHODS: A total of 1472 women with ESRD undergoing hemodialysis were recruited to a multinational, cross-sectional study conducted within a collaborative dialysis network in Europe and South America. Sexual dysfunction was identified by the Female Sexual Function Index. Correlates of self-reported sexual dysfunction were identified by regression analyses., Results: Of the 1472 women, 659 completed questionnaires (45%). More than half (362 of 659 [55%]) lived with a partner, and 232 of 659 (35%) reported being sexually active. Of these 659 respondents, 555 (84%) reported sexual dysfunction. Women with a partner (282 of 362 [78%]) were less likely to report sexual dysfunction than those without a partner (273 of 297 [92%]) (P<0.001). Sexual dysfunction was independently associated with age, depressive symptoms, less education, menopause, diabetes, and diuretic therapy. Nearly all women who were not wait-listed for a kidney transplant and were living without a partner (249 of 260 [96%]) reported sexual dysfunction. More than half (128 of 232 [55%]) of sexually active women reported sexual dysfunction, associated with age, depressive symptoms, menopause, low serum albumin, and diuretic therapy., Conclusions: This descriptive study suggests most women on hemodialysis experience sexual problems. Additional research on the relevance of sexual dysfunction to symptom burden and quality of life in these women is needed.

Background: Factors associated with erectile dysfunction in men on haemodialysis are incompletely identified due to suboptimal existing studies. We determined the prevalence and correlates of erectile dysfunction and identified combinations of clinical characteristics associated with a higher risk of erectile dysfunction using recursive partitioning and amalgamation (REPCAM) analysis., Methods: We conducted a multinational cross-sectional study in men on haemodialysis within a collaborative network. Erectile dysfunction and depressive symptoms were evaluated using the erectile function domain of the International Index of Erectile Function questionnaire and the Center for Epidemiological Studies-Depression Scale, respectively., Results: Nine hundred and forty-six (59%) of 1611 eligible men provided complete data for erectile dysfunction. Eighty-three per cent reported erectile dysfunction and 47% reported severe erectile dysfunction. Four per cent of those with erectile dysfunction were receiving pharmacological treatment. Depressive symptoms were the strongest correlate of erectile dysfunction [adjusted odds ratio 2.41 (95% confidence interval (CI) 1.57-3.71)]. Erectile dysfunction was also associated with age (1.06, 1.05-1.08), being unemployed (1.80, 1.17-2.79) or receiving a pension (2.05, 1.14-3.69) and interdialytic weight gain (1.9-2.87 kg, 1.92 [CI 1.19-3.09]; >2.87 kg, 1.57 [CI 1.00-2.45]). Married men had a lower risk of erectile dysfunction (0.49, 0.31-0.76). The prevalence of erectile dysfunction was highest (94%) in unmarried and unemployed or retired men who have depressive symptoms., Conclusions: Most men on haemodialysis experience erectile dysfunction and are untreated. Given the prevalence of this condition and the relative lack of efficacy data for pharmacological agents, we suggest that large trials of pharmacological and non-pharmacological interventions for erectile dysfunction and depression are needed.

Background: Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively., Study Design: Systematic review and meta-analysis., Setting & Population: Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD)., Selection Criteria for Studies: Observational studies conducted in patients with CKD only or including a control group without CKD., Predictor: Type of study population., Outcomes: Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators., Results: 50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, -9.28; 95% CI, -12.92 to -5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods., Limitations: Suboptimal and lack of uniform assessment of outcome measures., Conclusions: Sexual dysfunction is highly prevalent in both men and women with CKD, especially among those on dialysis. Larger studies enrolling different ethnic groups, using validated study tools, and analyzing the influence of various factors on the development of sexual dysfunction are needed., (Copyright © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the association between disability and personal/lifestyle, medical, and psychosocial risk factors for upper extremity musculoskeletal symptoms and disorders (UEMSDs) in medical transcriptionists., Methods: A web-based survey involving the Disabilities of the Arm, Shoulder and Hand (DASH), Perceived Stress Scale (PSS) and Overall Job Satisfaction (OJS) questionnaires of all medical transcriptionists working at a large healthcare facility., Results: Responses were received from 80% (251 of 314) possible participants. Mean DASH, PSS, and OJS scores for those working at their current position for at least 1 year were 8.5 +/- 10.1, 14.3 +/- 6.7 and 5.3 +/- 0.9. Personal/lifestyle factors including age (P < 0.001), lower educational level (P = 0.014), current or previous smoking (P = 0.012), and limited exercise (P = 0.013); medical conditions including diabetes mellitus (P = 0.015), carpal tunnel syndrome (P < 0.001), prior treatment for upper extremity symptoms (P < 0.001); prior workstation evaluation (P < 0.001) and psychosocial factors of perceived stress (P < 0.001), are associated with increased DASH scores. In these workers, multivariate analysis suggests that medical conditions (finger or other upper extremity symptoms requiring treatment or workstation evaluation; and diabetes mellitus) have a larger effect on the DASH than personal/lifestyle or psychosocial factors (age; previous or current smoking; and perceived stress)., Conclusions: Prior upper extremity musculoskeletal symptoms requiring treatment or ergonomic assessment, high perceived stress and a history of smoking are associated with self-reported disability. Diabetics have significantly higher levels of upper extremity disability than non-diabetics. Prospective studies are needed to see if interventions addressing these factors will prevent future work disability.

Objective: To assess temporal trends in carpal tunnel syndrome (CTS) incidence, surgical treatment, and work-related lost time., Methods: Incident CTS and first-time carpal tunnel release among Olmsted County, Minnesota, residents were identified using the medical records linkage system of the Rochester Epidemiology Project; 80% of a sample were confirmed by medical record review. Work-related CTS was identified from the Minnesota Department of Labor and Industry., Results: Altogether, 10,069 Olmsted County residents were initially diagnosed with CTS in 1981-2005. Overall incidence (adjusted to the 2000 US population) was 491 and 258 per 100,000 person-years for women vs men (p < 0.0001) and 376 per 100,000 for both sexes combined. Adjusted annual rates increased from 258 per 100,000 in 1981-1985 to 424 in 2000-2005 (p < 0.0001). The average annual incidence of carpal tunnel release surgery was 109 per 100,000, while that for work-related CTS was 11 per 100,000. An increase in young, working-age individuals seeking medical attention for symptoms of less severe CTS in the early to mid-1980s was followed in the 1990s by an increasing incidence in elderly people., Conclusions: The incidence of medically diagnosed carpal tunnel syndrome (CTS) accelerated in the 1980s. The cause of the increase is unclear, but it corresponds to an epidemic of CTS cases resulting in lost work days that began in the mid-1980s and lasted through the mid-1990s. The elderly present with more severe disease and are more likely to have carpal tunnel surgery, which may have significant health policy implications given the aging population.

This article is a continuation of the story of the struggle to win recognition of physical medicine and rehabilitation as a medical specialty, as told in the pages of a daily diary kept by Frank H. Krusen, MD, from 1943 through 1967. The first two articles described Dr. Krusen's professional development before 1943, his efforts to establish a certifying Board for physiatrists, and the role of the Baruch Committee on Physical Medicine in Krusen's eventual successes. This article focuses on how Krusen and his physiatric colleagues campaigned to gain acceptance by organized medicine of the new specialty, to unite the fields of physical medicine and rehabilitation, and to identify and maintain the scope of physiatric practice despite challenges from other specialties.

This article, the last of four based on the diary of Dr. Frank H. Krusen, picks up the story of physiatry's conflict with other medical specialty groups within the American Medical Association. The conflict was focused on PM&R's use of the term "rehabilitation," but the underlying motive of groups opposing physical medicine was to limit the scope of physiatric practice. Dr. Krusen organized a well-documented and successful defense of the specialty and opened the door to the development of comprehensive care of persons with disabilities. Also related here are Dr. Krusen's legislative and public relations contributions to PM&R from 1963 until his retirement from Tufts-New England Medical Center in 1969. Dr. Krusen retired to Cape Cod and died there in 1973.

Frank H. Krusen, MD, was arguably the most influential member of the small group of physicians who began in 1938 a long and difficult struggle to win acceptance of physical medicine and rehabilitation as a medical specialty. The struggle was aided immeasurably in 1943 when a millionaire philanthropist, M. Bernard Baruch, financed the establishment of the Baruch Committee on Physical Medicine. Dr. Krusen became the Director-Secretary of the Committee and began to keep a daily diary in which he recorded his activities and those of his colleagues in their quest for recognition of PM&R as a specialized field of medical practice. That recognition came in 1947 with the establishment of the American Board of Physical Medicine, but Dr. Krusen continued his diary through 1967. In 1988, 15 years after his death, Dr. Krusen's family donated a copy of the diary to the History of Medicine Library of the Mayo Clinic in Rochester, MN. The gift coincided with the American Academy of Physical Medicine and Rehabilitation's celebration of its 50th anniversary. This article, the first of four, introduces the reader to Dr. Krusen and describes his early years and his professional development in the years before 1943.

Presented here is a continuation of the story--as drawn from the diary entries of Frank. H. Krusen. MD--of the struggle to gain recognition for, and acceptance of, physical medicine as a medical specialty in its own right. It details the events, as described by physical medicine's strongest protagonist, between 1943 and 1947 that led finally to the establishment of the American Board of Physical Medicine. The millionaire philanthropist Bernard Baruch provided the financial resources that were required to establish academic and clinical programs in the field of physical medicine. Dr. Krusen was a key member of the Baruch Committee on Physical Medicine, which provided over sight for the newly created programs. His thoughts and sentiments concerning his role in the struggle, as he recorded them in his diary, are reported here.