Managing Dyslipidemia in Chronic Kidney Disease

The incidence of chronic kidney disease (CKD) in the U.S. continues to increase, and now over 10% of the U.S. population has some form of CKD. Although some patients with CKD will ultimately develop renal failure, most patients with CKD will die of cardiovascular disease before dialysis becomes necessary. Patients with CKD have major proatherogenic lipid abnormalities that are treatable with readily available therapies. The severe derangements seen in lipoprotein metabolism in patients with CKD typically results in high triglycerides and low high-density lipoprotein (HDL) cholesterol. Because of the prevalence of triglyceride disorders in patients with CKD, after treating patients to a low-density lipoprotein goal, non-HDL should be calculated and used as the secondary goal of treatment. A review of the evidence from subgroup analysis of several landmark lipid-lowering trials supports treating dyslipidemia in mild to moderate CKD patients with HMG-CoA reductase inhibitors. The evidence to support treating dyslipidemia in hemodialysis patients, however, has been mixed, with several outcome trials pending. Patients with CKD frequently have mixed dyslipidemia and often require treatment with multiple lipid-lowering drugs. Although statins are the cornerstone of therapy for most patients with CKD, differences in their pharmacokinetic properties give some statins a safety advantage in patients with advanced CKD. Although most other lipid-lowering agents can be used safely with statins in combination therapy in patients with CKD, the fibrates are renally metabolized and require both adjustments in dose and very careful monitoring due to the increased risk of rhabdomyolysis. After reviewing the safety and dose alterations required in managing dyslipidemia in patients with CKD, a practical treatment algorithm is proposed

Health Care Advocacy: The Relationships between Age, Chronicity, Comorbidity, and Perceived Need for Assistance

Background and Purpose: The U.S. population is living longer; therefore, a relatively large proportion of the population is likely to experience chronic illnesses within their lifetime. An experimental study was conducted to examine factors influencing the likelihood of hiring a Health Care Advocate (HCA). Methods: Survey data were collected from a randomly selected community sample of participants (N = 470) over the age of 18 who were provided with a description of an HCA and a written vignette describing a medical scenario. Participants read one of eight vignettes in which they were asked to imagine they were in a car accident and required medical care. Age, injury (chronic vs. acute), and presence of comorbid chronic condition were manipulated. Results: A significant interaction indicated that when there was no pre-existing chronic health condition, sustaining a chronic injury increased the likelihood of hiring an HCA. In addition, younger adults with comorbid conditions were perceived as having greater need for an HCA than younger adults without comorbid conditions. Older adults were perceived as benefiting from HCAs regardless of comorbid conditions. Conclusion: This study demonstrates the need for patient-centered support for older adults following an injury, and for younger adults when a pre-existing chronic condition exists. Efforts should be made to target services to these populations of interest

Ethnic Differences in Perceptions of Alzheimer’s Disease: Implications for Seeking Assistance in Caring for an Ill Parent

Purpose: To examine ethnic differences in ratings of 1) condition severity, 2) need for medical assistance, and 3) likelihood of hiring a Healthcare Advocate (HCA) for an ill, elderly parent as a function of 1) parent’s cognitive state (Alzheimer’s disease [AD] or cognitively healthy), 2) parent’s physical malady (hip fracture or heart attack), and 3) distance (near or far from the parent), with an emphasis on the interaction between ethnicity and cognitive state. Method: Nine-hundred-seventy-four individuals who identified as White, Black, Hispanic, or Asian/Pacific Islander read a hypothetical vignette about an older man. The man’s physical malady (heart attack or hip fracture), cognitive state (AD or no AD), and physical distance from a close family member were manipulated in the vignette. Participants rated the severity of the medical condition and their likelihood of hiring an HCA. Results: Black and Asian/Pacific Islander participants did not differ from White participants on any outcomes. Unlike White participants, Hispanic participants did not rate the older man’s condition as more severe and were not more likely to seek assistance when he had AD than when he was cognitively healthy. Conclusion: Ethnic differences in perceptions of AD may be less extensive than previously thought. The medical severity of AD did not appear to be recognized among the Hispanic participants in our sample, suggesting that culturallysensitive AD education may be particularly important in this subgroup

Demographic Predictors of the Perceived Likelihood of Hiring a Health Care Advocate

Background and Significance: The field of health care advocacy developed in response to the growing complexity of the health care system. A Health Care Advocate (HCA) is a trained professional who can help patients navigate the health care system. In the present study we investigated the effects of social support, number of people with whom individuals reside, gender, age, income, and race on the perceived likelihood of hiring an HCA for oneself. Method: Nine hundred and eighty-seven adults (Mage = 45.48 years, SD = 17.33 years, 55.4% female) were randomly selected and asked to complete a questionnaire. To explore the relationships of the perceived likelihood of hiring an HCA, path-analytic models using full-information maximum likelihood (FIML) estimation were tested, using Stata 12.1. Results: The model fit well statistically, ? 2 (5, N = 987) = 8.50, p = 0.131, and descriptively, CFI = 0.999, RMSEA = 0.027, pclose = 0.891, CD = 0.205. Conclusion: Overall, the model accounted for 4.30% of the variance in Hire HCA. More research is needed to better understand the role of an HCA in our complex and everchanging health care system

Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent

AbstractA case of Staphylococcus aureus renal artery stent infection was studied. Fourteen days after the procedure, the patient had a fever, hypotension, and an elevated white blood cell (WBC) count. Blood cultures were positive for S aureus on admission and during the patient's hospitalization, despite intravenous vancomycin therapy. Evaluation included serial CT scans, revealing increasing persistent inflammation with development of multiple renal intraparenchymal abscesses, and arteriography, showing marked degeneration of the renal artery. Therapy required resection of the renal artery/stent and nephrectomy. This case confirms the severe nature of S aureus stent infection; we recommend prophylactic antibiotics before these procedures, as well as expeditious evaluation and consideration for aggressive surgical therapy if this complication is suspected. (J Vasc Surg 1998;28:547-50.

A Landowner’s Guide to Common North American Predators of Upland-nesting Birds

Predation has been identified as a key factor limiting upland-nesting bird reproductive success in many studies. These results suggest that the effects of predation could be reduced by establishing and maintaining suitable nesting habitats. In several studies, habitat management alone was able to maintain populations of upland-nesting birds at or slightly above threshold believed necessary to sustain populations. However, additional studies also have shown that avian populations increased substantially after predator populations were reduced or nesting birds were protected by restricting predator access through the use of electric fencing or creating nesting islands. These practices, however, need to be implemented in combination with good habitat management if optimum benefits are to be realized

Label-Free Characterization of Organic Nanocarriers Reveals Persistent Single Molecule Cores For Hydrocarbon Sequestration

Self-assembled molecular nanostructures embody an enormous potential for new technologies, therapeutics, and understanding of molecular biofunctions. Their structure and function are dependent on local environments, necessitating in-situ/operando investigations for the biggest leaps in discovery and design. However, the most advanced of such investigations involve laborious labeling methods that can disrupt behavior or are not fast enough to capture stimuli-responsive phenomena. We utilize X-rays resonant with molecular bonds to demonstrate an in-situ nanoprobe that eliminates the need for labels and enables data collection times within seconds. Our analytical spectral model quantifies the structure, molecular composition, and dynamics of a copolymer micelle drug delivery platform using resonant soft X-rays. We additionally apply this technique to a hydrocarbon sequestrating polysoap micelle and discover that the critical organic-capturing domain does not coalesce upon aggregation but retains distinct single-molecule cores. This characteristic promotes its efficiency of hydrocarbon sequestration for applications like oil spill remediation and drug delivery. Such a technique enables operando, chemically sensitive investigations of any aqueous molecular nanostructure, label-free