Sphinganine is associated with 24-h MAP in the non-sleepy with OSA.

INTRODUCTION: Excessive daytime sleepiness is a debilitating symptom of obstructive sleep apnea (OSA) linked to cardiovascular disease, and metabolomic mechanisms underlying this relationship remain unknown. We examine whether metabolites from inflammatory and oxidative stress-related pathways that were identified in our prior work could be involved in connecting the two phenomena. METHODS: This study included 57 sleepy (Epworth Sleepiness Scale (ESS) ≥ 10) and 37 non-sleepy (ESS < 10) participants newly diagnosed and untreated for OSA that completed an overnight in-lab or at home sleep study who were recruited from the Emory Mechanisms of Sleepiness Symptoms Study (EMOSS). Differences in fasting blood samples of metabolites were explored in participants with sleepiness versus those without and multiple linear regression models were utilized to examine the association between metabolites and mean arterial pressure (MAP). RESULTS: The 24-h MAP was higher in sleepy 92.8 mmHg (8.4) as compared to non-sleepy 88.8 mmHg (8.1) individuals (P = 0.03). Although targeted metabolites were not significantly associated with MAP, when we stratified by sleepiness group, we found that sphinganine is significantly associated with MAP (Estimate = 8.7, SE = 3.7, P = 0.045) in non-sleepy patients when controlling for age, BMI, smoking status, and apnea-hypopnea index (AHI). CONCLUSION: This is the first study to evaluate the relationship of inflammation and oxidative stress related metabolites in sleepy versus non-sleepy participants with newly diagnosed OSA and their association with 24-h MAP. Our study suggests that Sphinganine is associated with 24 hour MAP in the non-sleepy participants with OSA.

Gait Speed and Mortality, Hospitalization, and Functional Status Change Among Hemodialysis Patients: A US Renal Data System Special Study.

BACKGROUND: Slow walk (gait) speed predicts functional decline, institutionalization, and mortality risks in the geriatric population. A gait speed evidence base for dialysis patient outcomes is needed. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 752 prevalent hemodialysis (HD) patients aged 20 to 92 years evaluated in 2009 to 2012 in 7 Atlanta and 7 San Francisco clinics in a US Renal Data System special study. PREDICTOR: Usual walk speed in meters per second, categorized as ≥0.6 m/s (baseline n=575), <0.6 m/s (baseline n=94), and unable to perform walk test (baseline n=83). OUTCOMES: Survival; hospitalization; activities of daily living (ADL) difficulty; 36-Item Short Form Health Survey (SF-36) Physical Function score. MEASUREMENTS: Cox proportional hazards models investigated gait speed and mortality over a median follow-up of 703 days. Multivariable logistic or linear regression models estimated associations of baseline gait speed with hospitalization, need for ADL assistance, and SF-36 Physical Function score after 12 months. RESULTS: Participants who walked ≥0.6 m/s had 53 (9%) deaths, those who walked <0.6 m/s had 19 (20%) deaths, and those unable to walk had 37 (44%) deaths. Adjusted mortality hazard ratios were 2.17 (95% CI, 1.19-3.98) for participants who walked <0.6 m/s and 6.93 (95% CI, 4.01-11.96) for those unable to walk, compared with participants walking ≥0.6 m/s. After 12 months, compared with baseline walk speed ≥ 1.0 m/s (n=169 participants), baseline walk speed of 0.6 to <0.8 m/s (n=116) was associated with increased odds of hospitalization (OR, 2.04; 95% CI, 1.19-3.49) and ADL difficulty (OR, 3.88; 95% CI, 1.46-10.33) and a -8.20 (95% CI, -13.57 to -2.82) estimated change in SF-36 Physical Function score. LIMITATIONS: Cohort not highly representative of overall US in-center HD population. CONCLUSIONS: Because walking challenges the heart, lungs, and circulatory, nervous, and musculoskeletal systems, gait speed provides an informative marker of health status. The association of gait speed with HD patients' risk for functional decline warrants continued study.

Estimated pulmonary artery systolic pressure and self-reported physical function in patients on hemodialysis.

BACKGROUND/AIMS: Patients on chronic hemodialysis have a high prevalence of heart disease and poor self-reported physical function. The association between structural heart disease and self-reported physical function in patients on hemodialysis is unknown. METHODS: We studied the association between elevated pulmonary artery systolic pressure (PASP) and self-reported physical function in ESRD in 253 patients in the USRDS ACTIVE/ADIPOSE study between 2009 and 2011. We used multivariate linear regression with PASP obtained from clinical echocardiogram reports as the primary predictor and the Physical Function (PF) subscale of the SF-36 as the primary outcome. To determine whether associations between PASP and PF were driven by fluid overload or left ventricular hypertrophy, we assessed whether PASP was associated with bioimpedance spectroscopy (BIS)-derived extracellular water (ECW) and with left ventricular posterior wall thickness. RESULTS: In a multivariable model, each 10 mm Hg higher PASP was associated with a 3.32-point lower PF score (95% CI -5.95, -0.68). In a multivariable model that included BIS estimates, both left ventricular posterior wall thickness (LVPW, per 5 mm) and ECW were associated with a higher PASP (LVPW 4.21 mm Hg, 95% 0.38-8.04; ECW 1.12 mm Hg per liter, 95% CI 0.07-2.18). Higher LVPW and ECW were independently associated with a lower PF score. CONCLUSION: Left ventricular hypertrophy and elevated pulmonary pressure are associated with worse self-reported physical function in patients on hemodialysis. The role of chronic volume overload on PASP and PF score should be evaluated in a prospective manner.

Underreporting of nursing home utilization on the CMS-2728 in older incident dialysis patients and implications for assessing mortality risk.

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.

Association of physical function with predialysis blood pressure in patients on hemodialysis.

BACKGROUND: New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. METHODS: We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. RESULTS: Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI 0.35-0.93) of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand (130-159 mmHg: OR 0.59, 95% CI 0.38-0.92) and gait speed (≥160 mmHg: OR 0.59, 95% CI 0.35-0.98). Blood pressure≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg. CONCLUSIONS: Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined.

Calibration of the brief food frequency questionnaire among patients on dialysis.

OBJECTIVE: Estimating dietary intake is challenging in patients with chronic diseases. The aim of this study was to calibrate the Block Brief 2000 food frequency questionnaire (BFFQ) using 3-day food diary records among patients on dialysis. METHODS: Data from 3-day food diary records from 146 patients new to dialysis were reviewed and entered into National Cancer Institute self-administered 24-hour dietary recall (ASA24), a web-based dietary interview system. The information was then re-entered omitting foods reported in the diaries that were not in the BFFQ to generate a "BFFQ-restricted" set of intakes. We modeled each major dietary component (i.e., energy [total calories], protein, carbohydrate, fat) separately using linear regression. The main independent variables were BFFQ-restricted food diary estimates computed as the average of the 3 days of diaries, restricted to items included in the BFFQ, with the unrestricted 3-day food diary averages as dependent variables. RESULTS: The BFFQ-restricted diary energy estimate of 1,325 ± 545 kcal was 87% of the energy intake in the full food diary (1,510.3 ± 510.4, P < .0001). The BFFQ-restricted diary carbohydrate intake was 83% of the full food diary (156.7 ± 78.7 g vs. 190.4 ± 72.7, P < .0001). The BFFQ-restricted fat intake was 90% of the full-diary-reported fat intake (50.1 ± 24.1 g vs. 56.4 ± 21.6 g, P < .0001). Daily protein intake assessments were not statistically different by BFFQ-restricted diary and full diary assessment (63.1 ± 28.5 vs. 64.1 ± 21.4 g, P = .60). The associations between BFFQ-restricted diary intake and unrestricted intake were linear. Three-day diary-reported intake could be estimated from BFFQ-restricted intake with r2 ranging from 0.36 to 0.56 (P < .0001 for energy [total calories], protein, carbohydrate, and fat). Final equations did not include adjustments for age, sex, or race because the patterns of associations were not significantly different. CONCLUSION: Energy and macronutrient estimates by BFFQ are lower than estimates from 3-day food diaries, but simple calibration equations can be used to approximate total intake from BFFQ responses.

Frailty as a dynamic process in a diverse cohort of older persons with dialysis-dependent CKD.

This study examines frailty status evolution observed in a two-year follow-up of a cohort of older persons (age ≥65) with chronic kidney disease (CKD) undergoing maintenance hemodialysis (HD) treatment. Frailty, a geriatric syndrome that connotes a state of low physiologic reserve and vulnerability to stressors, is associated with increased risk for multiple adverse health outcomes in studies of persons with CKD as well as older persons in the general population. The Fried frailty index defines frailty as the presence of 3 or more of 5 indicators-recent unintentional weight loss, slowed gait speed, decreased muscle strength, self-reported exhaustion, and low physical activity. In the seminal work by Fried and colleagues, persons who were characterized by 1-2 of the Fried index criteria were termed "pre-frail" and considered at risk for subsequently becoming frail, potentially providing insight regarding intervention targets that might slow or prevent individuals' transition from pre-frail to frail status. Other less frequently studied types of transitions may also be informative, including "recovery or reversion" (improvement) by people whose longitudinal assessments indicate movement from frailty to prefrailty or robust, or from prefrailty to robust. These status changes are also a potential source of insights relevant for prevention or remediation of frailty, but research focusing on the various ways that individuals may transition between frailty states over time remains limited, and no previous research has examined varying patterns of frailty status evolution in an older cohort of persons with dialysis-dependent CKD. In a study cohort of dialysis-dependent older persons, we characterized patterns of frailty status evolution by age, sex, race/ethnicity, and treatment vintage; by longitudinal profiles of non-sedentary behavior; and by self-report indicators relevant for dimensions emphasized in the Age-Friendly 4Ms Health System (What Matters, Mobility, Mentation). Our study suggests that strategies to promote resiliency among older persons with dialysis-dependent CKD can be informed not only by frailty status transition that indicates improvement over time but also by older adults' maintenance of (stable) robust status over time, and we concur that inclusion of both frailty and resilience measures is needed in future longitudinal studies and clinical trials.

Impact of race on predialysis discussions and kidney transplant preemptive wait-listing.

BACKGROUND/AIMS: US registry data have consistently shown that blacks are less likely than whites to be wait-listed before beginning dialysis. METHODS: The Comprehensive Dialysis Study (CDS) was a special study conducted by the US Renal Data System (USRDS) in which a national cohort of patients who began maintenance dialysis therapy in 2005-2007 were asked whether kidney transplantation (KT) had been discussed with them before they started dialysis. Using responses from black and white CDS participants and information from the USRDS, we investigated preemptive wait-listing as a function of patient-reported predialysis KT discussion. RESULTS: Among those reporting early KT discussion, 31.0% of patients preemptively wait-listed were black, compared to 27.5% of those not preemptively wait-listed. Two thirds of preemptively wait-listed patients had received nephrology care more than 12 months before starting dialysis and reported that KT was discussed with them 12 months or more before dialysis. Early KT discussion and higher serum albumin and hemoglobin levels remained significant predictors of preemptive wait-listing in an adjusted logistic regression analysis. Among those preemptively wait-listed, 33% of blacks and 60% of whites had received a transplant by September 30, 2009 (study end date). CONCLUSION: Early KT discussion appeared to reduce barriers to black patients' waiting list placement before the start of dialysis, which in turn may facilitate earlier access to a deceased donor organ transplant.

Low level of self-reported physical activity in ambulatory patients new to dialysis.

Physical inactivity contributes to the frailty and the decline in function that develops over time among patients with end-stage renal disease. We assessed physical activity among 1547 ambulatory patients new to dialysis in the United States Renal Data System Comprehensive Dialysis Study. We used a self-reporting Human Activity Profile that included Maximal and Adjusted Activity Scores and compared results to established norms by age and gender. Physical activity was found to be extremely low with scores for all age and gender categories below the 5th percentile of healthy individuals and 95% of patients had scores consonant with low fitness. Older age, female gender, diabetes, atherosclerotic disease, and a low level of education were associated with lower activity scores assessed by univariate and multivariable linear regression analysis. Higher serum albumin, creatinine, and lower body mass index, but not hemoglobin levels, were associated with greater physical activity. By multivariable analysis, patients on hemodialysis using a catheter reported lower levels of physical activity compared to those on peritoneal dialysis, hemodialysis using an arteriovenous fistula, or with a graft. Lower Maximal and Adjusted Activity Scores were associated with poor physical function and mental health. Hence, physical activity is distressingly low among patients new to dialysis. Thus, strategies to enhance activity in these patients should be explored.

Improving psychosocial health in hemodialysis patients after a disaster.

Twenty-two social workers implemented a cognitive-behavioral intervention with 69 patients in 22 dialysis units in Louisiana to improve psychosocial health following Hurricanes Katrina and Rita. Pre- and post-intervention questionnaires measured psychosocial status domains (general health status, social functioning, burden of kidney disease, depressed mood, anxiety, and mastery). Participants rated their general health status (p < .05) and social functioning (p < .05) significantly higher after the intervention. Participants who listened to the class Managing stress through communication and problem solving and discussed it with their social worker, had significant improvement in depressed mood score (p < .05) after completing the program, compared to participants who did not discuss this material with their social worker. Sixty-five percent had scores indicating depressed mood before the program, compared with 56% following. The more positive participants' program evaluation, the higher their quality of life (lower perceived burden of kidney disease [p = .05]).

Sleep Disturbances in MCI and AD: Neuroinflammation as a Possible Mediating Pathway.

Mild cognitive impairment (MCI) and Alzheimer's disease (AD) affect a high proportion of the elderly population with an increasing prevalence. Sleep disturbances are frequent in those with MCI and AD. This review summarizes existing research on sleep disturbances and neuroinflammation in MCI and AD. Although strong evidence supports various pathways linking sleep and AD pathology, the temporal direction of this central relationship is not yet known. Improved understanding of sleep disturbance and neuroinflammation in MCI and AD may aid in the identification of targets for their prevention.

Missed dialysis sessions and hospitalization in hemodialysis patients after Hurricane Katrina.

In order to evaluate the factors that contributed to missed dialysis sessions and increased hospitalizations of hemodialysis patients after Hurricane Katrina, we contacted 386 patients from 9 New Orleans hemodialysis units. Data were collected through structured telephone interviews on socio-demographics, dialysis factors, and evacuation characteristics. Overall, 44% of patients reported missing at least one and almost 17% reported missing 3 or more dialysis sessions. The likelihood of missing 3 or more sessions was greater for those whose dialysis vintage was less than 2 years compared to those for whom it was 5 or more years, who had 38 or fewer billed dialysis sessions compared to those who had 39 or more in the 3 months before the storm, who lived alone before the storm, who were unaware of their dialysis facility's emergency plans, who did not evacuate prior to hurricane landfall, and who were placed in a shelter. The adjusted odds ratio of hospitalization among patients who missed 3 or more compared to those who did not miss any dialysis sessions was 2.16 (95% CI: 1.05-4.43). These findings suggest that when preparing for future disasters more emphasis needs to be placed on patient awareness and early execution of emergency plans.

Effect of Hurricane Katrina on the mortality of dialysis patients.

To investigate whether Hurricane Katrina's landfall in August 2005 resulted in excess mortality, we conducted a cohort study of patients who started dialysis between January 2003 and late August 2005 and who received treatment at 94 Katrina-affected clinics in the area. Survival, regardless of patient location after the storm, was followed through February 2006. In adjusted Cox proportional hazards models, Hurricane Katrina (time-varying indicator) was not significantly associated with mortality risk for patients from regions of the Gulf Coast affected by Katrina or those from a subset of 40 New Orleans clinics. Subgroup analyses indicated no significant increased mortality risk by race, income status, or dialysis modality. Sensitivity analyses indicated no significant increased mortality risk for patients from clinics closed for 10 days or longer, patients in their first 90 days of dialysis, or patients not evacuated from the affected areas. Patients remaining in the New Orleans area may have been more vulnerable due to age and comorbidities; however, the change in their mortality risk in the month following the storm was not statistically significant. We suggest that disaster-related education for patients must be ongoing, and that each disaster may present a different set of circumstances and challenges that will require unanticipated response efforts.

Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study.

We estimated the survival and hospitalization among frequent hemodialysis users in comparison to those patients undergoing thrice-weekly conventional hemodialysis. All patients had similar characteristics and medical histories. In this cohort study of frequent hemodialysis users and propensity score-matched controls, the collaborating clinicians identified 94 patients who used nocturnal hermodialysis (NHD) and 43 patients who used short-duration daily hemodialysis (SDHD) for a minimum of 60 days. Ten propensity score-matched control patients for each NHD and SDHD patient were identified from the United States Renal Data System database. Primary outcomes were risk for all-cause mortality and risk for the composite outcome of mortality or major morbid event (acute myocardial infarction or stroke) estimated using Cox proportional hazards models. Risks for all-cause, cardiovascular-related, infection-related, and vascular access-related hospital admissions were also studied. Nocturnal hemodialysis was associated with significant reductions in mortality risk and risk for mortality or major morbid event when compared to conventional hemodialysis. There was a reduced but non-significant risk of death for patients using SDHD compared to controls. All-cause and specific hospitalizations did not differ significantly between NHD and SDHD patients and their matched control cohorts. Our study suggests that NHD may improve patient survival.

Costs and effectiveness of cardiac rehabilitation for dialysis patients following coronary bypass.

Dialysis patients have a high risk of cardiovascular disease. Cardiac rehabilitation is recommended in the general population as a standard component of care and covered by Medicare for those who have undergone coronary artery bypass grafting (CABG). Here we determined the impact of cardiac rehabilitation on Medicare expenditures and its cost effectiveness in dialysis patients. A cohort of 4,324 patients with end-stage renal disease who began chronic hemodialysis and had undergone CABG over a seven year period were selected from the United States Renal Data System. Cardiac rehabilitation was defined by Current Procedural Terminology codes for monitored and non-monitored exercise in Medicare claims data. Medicare expenditures included in and outpatient claims adjusted to 1998 dollars. Over a 42-month follow-up, cardiac rehabilitation at baseline was associated with higher cumulative Medicare expenditures but this increase was not statistically significant. During the same period, cardiac rehabilitation was significantly associated with longer cumulative life, having an incremental benefit of 76 days. The incremental cost-effectiveness ratio of $13,887 per year of life saved suggests that cardiac rehabilitation is highly cost-effective in patients with end-stage renal disease following CABG.

Promoting functioning and well-being in older CKD patients: review of recent evidence.

Osteoporosis, falls, sleep difficulty, cognitive impairment, and depressed mood are major clinical concerns in the geriatric population that are physiologically and psychologically based and are often interrelated. All of these issues have implications for patients' daily functioning and quality of life (QOL). This review synthesizes recent evidence about these prominent issues in geriatric care and related implications for care of older patients with chronic kidney disease (CKD). Recent evidence about pre-dialysis and dialysis treatment strategies that may help to optimize management of older patients is also considered. Although elderly patients often report better psychosocial adjustment to dialysis than do younger patients, physical functioning and cognitive functioning losses challenge the QOL of many elderly persons. Early management of CKD and attention to anemia, consideration of the benefits of peritoneal dialysis compared with hemodialysis, and inclusion of some form of exercise or regular physical activity in routine care provide key opportunities to enhance the functioning and well-being of older patients.

Patient-reported sleep difficulty and cognitive function during the first year of dialysis.

BACKGROUND: Research in the general population indicates that sleep fragmentation is detrimental for cognitive function, but little attention has been given to this issue in dialysis patients. We hypothesized that patients with self-reported persistent sleep difficulty would have an increased risk of scoring lower on a cognitive function measure at follow-up compared to their score at baseline. METHODS: Sleep difficulty and cognitive function were reported by a large national patient cohort near the start of dialysis and at a 9- to 12-month follow-up. Logistic regression was used to investigate the risk of scoring lower on a cognitive function measure at follow-up as a function of self-reported sleep difficulty, controlling for patients' sociodemographic, clinical and treatment characteristics, including depressed mood. RESULTS: At follow-up, cognitive function scores were lower among 35.8% of the cohort. Patients with self-reported persistent sleep difficulty had the lowest average cognitive function score. Men with reported persistent sleep difficulty, regardless of presence of depressed mood, had a significantly increased risk of a lower cognitive function score at follow-up. Women with reported persistent sleep difficulty as well as depressed mood had significantly increased risk of a lower cognitive function score. CONCLUSION: The potential impact of sleep difficulty and depressed mood on the cognitive function of dialysis patients emphasizes the importance of evaluating and treating these risks and highlights the value of continued research to improve our understanding and management of these issues.

Acupuncture for Treatment of Persistent Disturbed Sleep: A Randomized Clinical Trial in Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder.

OBJECTIVE: To evaluate real, as compared with sham, acupuncture in improving persistent sleep disturbance in veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD). METHODS: This sham-controlled randomized clinical trial at a US Department of Veterans Affairs Medical Center (2010-2015) included 60 veterans aged 24-55 years (mean of 40 years) with history of mTBI of at least 3 months and refractory sleep disturbance. Most of these participants (66.7%) carried a concurrent DSM-IV clinical diagnosis of PTSD. For the present study, they were randomized into 2 groups and stratified by PTSD status using the PTSD Checklist-Military Version. Each participant received up to 10 treatment sessions. The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy-assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate. RESULTS: Mean (SD) preintervention global PSQI score was 14.3 (3.2). Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, P = .04) and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, P = .0016). Effective blinding for active treatment was maintained in the study. PTSD participants presented with more clinically significant sleep difficulties at baseline; acupuncture was effective for both those with and without PTSD. CONCLUSIONS: Real acupuncture, compared with a sham needling procedure, resulted in a significant improvement in sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD. These results indicate that an alternative-medicine treatment modality like acupuncture can provide clinically significant relief for a particularly recalcitrant problem affecting large segments of the veteran population. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01162317.

How can exercise be incorporated into the routine care of patients on dialysis?

Regular physical activity and exercise can have many beneficial effects for dialysis patients. The provision of an opportunity for patients to exercise at their treatment center has several advantages, but almost any method of increasing activity is likely to be beneficial. In addition to in-center programs such as cycling exercise before or during dialysis, other exercise options include participation in community-based walking programs, water exercise or swimming, yoga, Tai Chi, or low-level strengthening programs. Physical therapy that is individualized to meet patients' needs is also especially appropriate for older persons. The essential condition is that the unit and staff are committed to a treatment culture that makes physical activity a priority. Asking patients what they are doing for regular exercise should be part of routine patient assessment.