Kidney biopsy-based management of maintenance immunosuppression is safe and may ameliorate flare rate in lupus nephritis.

The optimal duration of maintenance immunosuppressive therapy for patients with lupus nephritis who have achieved clinical remission has not been established. Furthermore, clinical and histologic remissions are often discordant. We postulated that continuing therapy for patients with persistent histologic activity on kidney biopsies done during maintenance and discontinuing therapy only for patients without histologic activity would minimize subsequent lupus nephritis flares. To test this, a cohort of 75 prospectively-followed patients with proliferative lupus nephritis was managed using kidney biopsies performed during maintenance therapy. These patients had been on immunosuppression for at least 42 months, had responded, and had maintained their clinical response for at least 12 months before the kidney biopsy was repeated. Maintenance therapy was withdrawn if the biopsy showed an activity index of zero, but was continued if the biopsy showed an activity index of one or more. A lupus nephritis flare developed in seven patients during the average 50 months from the third biopsy and the final clinic visit for a flare rate of 1.5/year; significantly less than reported flare rates. Baseline clinical parameters (serum creatinine, proteinuria) and serologic parameters (complement C3, C4 and anti-dsDNA) did not predict an activity index of zero on the third biopsy or who would have a lupus nephritis flare. No patients developed end-stage kidney disease. Four patients developed de novo chronic kidney disease. There were no serious adverse events related to biopsy. Thus, at an experienced center, biopsy-informed management of maintenance immunosuppression is safe and may improve the lupus nephritis flare rate compared to conventional clinical management.

The role of travel distance and price promotions in tobacco product purchase quantity.

INTRODUCTION: Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. Purchase decisions are likely to affect tobacco use behavior. Therefore, explanation of variation in tobacco purchase quantity by factors associated with rural vulnerability and factors that fall under the regulatory scope of the Tobacco Control Act (TCA) of 2009 could be of value to regulatory proposals intended to equitably benefit public health. METHODS: Our sample included 54 combustible tobacco users (298 purchase events) and 27 smokeless tobacco users (112 purchase events), who were asked to report all tobacco purchases on a smartphone application. We used an ecological momentary assessment methodology to collect data about tobacco users' purchasing patterns, including products, quantity purchased, and use of price promotions. A parent cohort study provided relevant data for home-outlet distance calculation and covariates. Our analysis examined associations between our outcome-purchase quantity per purchase event-and distance from participant's home to the nearest outlet, whether a price reducing promotion was used, and the interaction of these two factors. RESULTS: Combustible users showed an increased cigarette pack purchase quantity if they lived further from an outlet and used a price promotion (i.e., an interaction effect; RR = 1.70, 95% CI [1.11, 2.62]). Smokeless users purchased more units of snuff when they used price promotions (RR = 1.81, 95% CI [1.02, 3.20]). CONCLUSIONS: Regulatory action that imposes restrictions on the availability or use of price promotions could alter the purchasing behavior of rural Americans in such a way that makes it easier to reduce tobacco use or quit. Such action would also restrict flexibility in the price of tobacco products, which is known as a powerful tobacco control lever.

Impact of a Worksite Diabetes Prevention Intervention on Diet Quality and Social Cognitive Influences of Health Behavior: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the impact of a worksite diabetes prevention intervention on secondary outcomes regarding the change in diet quality and components of the Health Action Process Approach (HAPA) theoretical framework. DESIGN: Pretest-posttest control group design with 3-month follow-up. SETTING: University worksite. PARTICIPANTS: Employees aged 18-65 years with prediabetes (n = 68). INTERVENTION: A 16-week group-based intervention adapted from the Diabetes Prevention Program. MAIN OUTCOME MEASURES: Diet quality was assessed using the Alternative Healthy Eating Index 2010; HAPA components were assessed via written questionnaire. ANALYSIS: Repeated-measures ANOVA compared the between- and within-group change in outcomes across time. RESULTS: Significant difference occurred between groups for the change in consumption of nuts/legumes and red/processed meats postintervention and for fruits at 3-month follow-up (all P < .05); a significant increase in total Alternative Healthy Eating Index 2010 score occurred postintervention in the experimental group (P = .002). The changes in action planning, action self-efficacy, and coping self-efficacy from HAPA were significantly different between groups after the intervention; the change in outcome expectancies was significantly different between groups at 3-month follow-up (all P < .05). CONCLUSIONS AND IMPLICATIONS: The worksite intervention facilitated improvement in diet quality and in planning and efficacious beliefs regarding diabetes prevention. Further research is needed to evaluate the long-term impact of the intervention.

A Randomized Controlled Trial Translating the Diabetes Prevention Program to a University Worksite, Ohio, 2012-2014.

INTRODUCTION: Working adults spend much time at the workplace, an ideal setting for wellness programs targeting weight loss and disease prevention. Few randomized trials have evaluated the efficacy of worksite diabetes prevention programs. This study evaluated the efficacy of a worksite lifestyle intervention on metabolic and behavioral risk factors compared with usual care. METHODS: A pretest-posttest control group design with 3-month follow-up was used. Participants with prediabetes were recruited from a university worksite and randomized to receive a 16-week lifestyle intervention (n = 35) or usual care (n = 34). Participants were evaluated at baseline, postintervention, and 3-month follow-up. Dietary intake was measured by a food frequency questionnaire and level of physical activity by accelerometers. Repeated measures analysis of variance compared the change in outcomes between and within groups. RESULTS: Mean (standard error [SE]) weight loss was greater in the intervention (-5.5% [0.6%]) than in the control (-0.4% [0.5%]) group (P < .001) postintervention and was sustained at 3-month follow-up (P < .001). Mean (SE) reductions in fasting glucose were greater in the intervention (-8.6 [1.6] mg/dL) than in the control (-3.7 [1.6] mg/dL) group (P = .02) postintervention; both groups had significant glucose reductions at 3-month follow-up (P < .001). In the intervention group, the intake of total energy and the percentage of energy from all fats, saturated fats, and trans fats decreased, and the intake of dietary fiber increased (all P < .01) postintervention. CONCLUSION: The worksite intervention improved metabolic and behavioral risk factors among employees with prediabetes. The long-term impact on diabetes prevention and program sustainability warrant further investigation.

Self-administered Gerocognitive Examination (SAGE): a brief cognitive assessment Instrument for mild cognitive impairment (MCI) and early dementia.

OBJECTIVES: To develop a self-administered cognitive assessment instrument to facilitate the screening of mild cognitive impairment (MCI) and early dementia and determine its association with gold standard clinical assessments including neuropsychologic evaluation. METHODS: Adults aged above 59 years with sufficient vision and English literacy were recruited from geriatric and memory disorder clinics, educational talks, independent living facilities, senior centers, and memory screens. After Self-administered Gerocognitive Examination (SAGE) screening, subjects were randomly selected to complete a clinical evaluation, neurologic examination, neuropsychologic battery, functional assessment, and mini-mental state examination (MMSE). Subjects were identified as dementia, MCI, or normal based on standard clinical criteria and neuropsychologic testing. RESULTS: Two hundred fifty-four participants took the SAGE screen and 63 subjects completed the extensive evaluation (21 normal, 21 MCI, and 21 dementia subjects). Spearman rank correlation between SAGE and neuropsychologic battery was 0.84 (0.76 for MMSE). SAGE receiver operating characteristics on the basis of clinical diagnosis showed 95% specificity (90% for MMSE) and 79% sensitivity (71% for MMSE) in detecting those with cognitive impairment from normal subjects. CONCLUSIONS: This study suggests that SAGE is a reliable instrument for detecting cognitive impairment and compares favorably with the MMSE. The self-administered feature may promote cognitive testing by busy clinicians prompting earlier diagnosis and treatment.

Energy expenditure estimated by accelerometry and doubly labeled water: do they agree?

PURPOSE: The purpose of this study was to compare energy expenditure derived from regression equations determined from accelerometry with energy expenditure obtained from the doubly labeled water method (DLW). METHODS: Thirteen subjects participated in a 7-d protocol during which total daily energy expenditure (TDEE) was measured with DLW. Simultaneously, during the 7 d, subjects wore a Tritrac-R3D and an Actigraph (ACT). Pearson and concordance correlations and one-sample t-tests were used to determine the agreement of six Tritrac and eight ACT regression equations that convert body acceleration to energy expenditure with the DLW measurements. RESULTS: Tritrac TDEE determined from the different Tritrac regression equations under- and overestimated TDEE determined with DLW that ranged from -10 to +101%. For ACT, the percent difference between DLW and ACT-TDEE determined with the regression equation developed by Hendelman and Swartz were not statistically significantly different from zero. The mean of the difference was -2 and -4%, but the range of the difference was large for both equations, -29 to +24%. TDEE determined with the six other ACT equations were significantly different compared with DLW. CONCLUSION: Of the 14 different regression equations from the literature, only two developed for ACT compared favorably with DLW; however, the difference in TDEE between these two methods was variable and rather large. These results reemphasize the difficulty in converting body movement into energy expenditure on an individual basis from accelerometry. These results imply that researchers may want to avoid using accelerometers to predict energy expenditure in free-living conditions, instead using these instruments only to measure patterns of physical activity.