Cognitive impairment, perceived medication adherence, and high-risk medication use in patients with reduced kidney function: A cross-sectional analysis.

Background and Aims: Reduced estimated glomerular filtration rate (eGFR < 60 ml/min/1.73 m2) is a risk factor for cognitive impairment (CI) and medication nonadherence. However, the association between CI and medication adherence in adults with reduced eGFR has not been adequately examined. Our pragmatic objectives were to assess the cross-sectional relationship between CI and self-reported medication adherence, medication number, and use of potentially high-risk medications among adults with reduced eGFR. Methods: An observational cohort study of the epidemiology of CI in community-dwelling adults aged 45 years or older with reduced eGFR. Results: Our analytic cohort consisted of 420 participants (202 with CI; mean age: 69.7 years) with reduced eGFR, at least one prescription medication, and nonmissing medication adherence data. Participants with CI had four times greater unadjusted odds of reporting good medication adherence than participants without CI (self-report of missing medications <4 days/month; odds ratio [OR]: 4.04, 95% confidence interval [CI]:​​​​​ 1.62-10.10). This difference persisted following adjustment for demographic factors and comorbidities (OR: 5.50, 95% CI: 1.86-16.28). Participants with CI were no more likely than participants without CI to report forgetfulness as a reason for missing medication doses. Participants with CI were, on average, taking more total (mean: 13.3 vs. 11.5, median: 12 vs. 11) and more high-risk (mean: 5.0 vs. 4.2, median: 5 vs. 4) medications than those without CI; these differences were attenuated and no longer significant following adjustment for demographics and comorbidities. Conclusion: Given the well-documented association between CI and medication nonadherence, better self-reported medication adherence among those with CI may represent perceptions of adherence rather than actual adherence. Participants with CI were, on average, taking more total and more high-risk medications than those without CI, suggesting a possible increased risk for adverse drug events. Our results highlight the potential risks of relying on self-reported medication adherence in reduced eGFR patients with CI.

Breastfeeding Among Pediatric Emergency Physicians: Rates, Barriers, and Support.

OBJECTIVES: Physician mothers are at risk for early cessation of breastfeeding, in part because of challenges associated with returning to work. Given the inherent unpredictability of emergency medicine practice, we hypothesized that pediatric emergency medicine (PEM) physicians would face unique challenges in continuing breastfeeding while working in their field. The aims of this study were to determine the 6-month breastfeeding rates of PEM physicians, gain insight into their experiences expressing breast milk while working in pediatric emergency departments, and determine factors that support or discourage successful breastfeeding. METHODS: This study was a cross-sectional survey of members of the American Academy of Pediatrics Section on Emergency Medicine via its quarterly membership survey program. Separate survey pathways were developed for respondents who had ever breastfed and those who had not. RESULTS: One hundred ninety-three responded; 91 had breastfed, and 102 had not. Of those who breastfed, 90% did so for 6 months or longer. Mean (SD) duration was 12.5 (7.1) months (range, 2-48 months). Of those who expressed milk at work, only 7.6% felt they "always" had sufficient time to pump; 32% felt they "always" had what they considered to be an appropriate location to pump. Breastfeeding duration rate of at least 6 months was higher for those (66%) who "sometimes" to "always" had access to what they felt were appropriate locations to pump than for those (34%) who "never" or "occasionally" did (98 vs 85%, P = 0.048). Eighty-six percent of respondents who had never breastfed reported being "very supportive" of expressing milk at work. CONCLUSIONS: Breastfeeding PEM physicians have high 6-month breastfeeding rates, and many express milk at work. Although colleagues report being supportive, barriers of perceived lack of sufficient time to pump and appropriate pumping locations remain.

Implementation of a Critical Asthma Protocol in a Pediatric ICU.

BACKGROUND: Protocol-driven therapy has been successful in managing patients with asthma on pediatric wards, but there is wide variability in ICU-level management that is often provider-dependent. This study aimed to determine if a standardized protocol for critical asthma treatment could improve clinical outcomes. METHODS: A pre-intervention cohort consisting of subjects age 2-18 y, excluding patients with airway obstruction that was not felt to be due to asthma, who were admitted to the ICU for critical asthma. Demographics and data along with medication administration information were gathered using the hospital electronic medical record. A post-intervention cohort was obtained over 13 months in an identical manner. The primary end point was time on continuous albuterol. Subjects adhering to the protocol were examined as a subset. RESULTS: 71 post-intervention subjects were compared with a historical cohort of 52 pre-intervention subjects over a similar time frame. There were no significant differences in demographic characteristics. Median time on continuous albuterol (14.4 h vs 8.1 h, P = .14) and secondary end points of median ICU length of stay (LOS), hospital LOS, and time from discontinuing continuous albuterol to transfer out of ICU were not significantly reduced in the post-intervention cohort. Overall adherence to the clinical protocol through completion was 42%. When comparing the pre-intervention cohort with the protocol-adherent subjects, significant reductions were seen in time on continuous albuterol (14.4 h vs 3.0 h, P < .001), ICU LOS (38.7 h vs 21.0 h, P < .001), and hospital LOS (2.8 d vs 1.7 d, P = .005). CONCLUSIONS: Implementation of an asthma protocol in the pediatric ICU did not result in significant improvements in time on continuous albuterol or hospital and pediatric ICU LOS, likely due to low adherence to the protocol. However, in subjects who did adhere to the protocol there were significant reductions in the outcome measures.

Today's Students, Tomorrow's Physicians: Opinions on Enacted and Prospective Health Care Policies.

Future physicians will be key stakeholders in the formation, implementation, and success of health care policies enacted during their careers, though little is known of their opinions of enacted and proposed policies since the 2016 U.S. presidential election. This study aimed to understand the opinions of medical students related to policies including, but not limited to, protections for people with pre-existing conditions, a public option on the private exchange, and single-payer health care. Online surveys were completed by 1,660 medical students at 7 U.S. medical schools between October 2017 and November 2017. The authors used multiple logistic regression to examine associations between student characteristics and support of policies. In total, 1,660 of 4,503 (36.9%) eligible medical students completed the survey. A majority of respondents identified 4 extant Affordable Care Act policies as important, including its protections for patients with pre-existing conditions (95.3%) and Medicaid expansion (77.8%). With respect to prospective reforms, 82.6% supported a public insurance option, and 70.5% supported a single-payer health care system. Only 2.2% supported reducing funding for Medicaid. Although views varied by sex, anticipated specialty, and political affiliation, medical students largely supported prospective policies that would expand insurance coverage and access to health care.

Looking to the Future: Medical Students' Views on Health Care Reform and Professional Responsibility.

PURPOSE: Although medical students will influence the future U.S. health care system, their opinions on the Patient Protection and Affordable Care Act (ACA) have not been assessed since the 2016 presidential election and elimination of key ACA provisions. Understanding medical students' views on health care policy and professional obligations can provide insight into issues that will be shaped by the next generation of physicians. METHOD: From October 2017 to November 2017, the authors conducted an electronic survey of medical students from seven U.S. institutions to elicit opinions regarding the ACA and their professional responsibility to address health policy. Participant demographics and responses were tabulated, and multiple logistic regression models were used to assess the associations of demographic characteristics with student opinions. RESULTS: Completed surveys were returned by 1,660/4,503 (36.9%) eligible medical students. Respondent demographics were similar to national estimates. In total, 89.1% (1,475/1,660) supported the ACA, and 82.0% (1,362/1,660) reported that they understood the health care law. Knowledge of the law's provisions was positively associated with support for the ACA (P < .001). Most students (85.8%; 1,423/1,660) reported addressing health policy to be a professional responsibility. Political affiliation was consistently associated with student opinions. CONCLUSIONS: Most medical students support the ACA, with greater levels of support among medical students who demonstrated higher levels of objective knowledge about the law. Furthermore, students indicated a professional responsibility to engage in health policy, suggesting that tomorrow's physicians are likely to participate in future health care reform efforts.

Hospital Course of Croup After Emergency Department Management.

OBJECTIVES: To describe inpatient management of patients with croup admitted from the emergency department (ED). METHODS: In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. RESULTS: We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. CONCLUSIONS: Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.

Use of a modified bubble continuous positive airway pressure (bCPAP) device for children in respiratory distress in low- and middle-income countries: a safety study.

Background: While bubble continuous positive airway pressure (bCPAP) is commonly used in low- and middle-income countries (LMIC) to support neonates with respiratory distress, there are limited non-invasive support options for non-neonatal children. Aim: To demonstrate safety of a new device designed to support children during respiratory distress in LMIC. Methods: A paediatric bCPAP device was designed called SEAL-bCPAP (Simplified Ear-plug Adapted-bCPAP). SEAL-bCPAP is constructed from inexpensive, easily obtainable materials. The nasal prong interface was modified from previously described neonatal bCPAP set-ups using commercial ear-plug material to improve nasal seal. A prospective interventional study was conducted to evaluate safety in children with respiratory distress treated with SEAL-bCPAP. Patients aged 30 days to 5 years presenting to a hospital in northern Uganda from July 2015 to June 2016 were screened. Those with moderate-severe respiratory distress and/or hypoxia despite nasal cannula oxygen were eligible for study. Enrolled patients were supported with SEAL-bCPAP until respiratory improvement or death. Complications attributable to SEAL-bCPAP were recorded. Clinical outcomes were compared with historical control pre-trial data. Results: Eighty-three of 87 enrolled patients were included in the final analysis. No patients had significant SEAL-bCPAP complications. Five patients had mild complications which resolved (four with nasal irritation and one with abdominal distention). Trial patients had significant (p < 0.0001) improvement in their TAL score, respiratory rate and O2sat after 2 h of SEAL-bCPAP. Fifty-two of 64 patients (62.7%) with severe illness at Time1 did not have severe illness at Time2 (after 2 h of SEAL-bCPAP) (p < 0.0001). Unadjusted mortality rates were 12.2% (6/49) and 9.6% (8/83), respectively, for pre-trial (historical control) and trial patients (p = 0.64); the study was not powered to show efficacy. Conclusions: The SEAL-bCPAP device is safe for treatment of respiratory distress in non-neonatal children in LMIC. There is a trend toward decreased mortality that should be evaluated with adequately powered clinical trials.

A comparison of the vending environment among three rural subtypes of secondary schools.

The purpose of this study was to further explore the rural school food environment. This study assessed trends in prevalence of vending machines and vending items within and between Minnesota schools located in 3 rural subtypes: town/rural fringe, town/rural distant, and remote rural. Generalized estimating equation models were employed to analyze data from the 2006 through 2012 School Health Profiles Principal's Surveys (Profiles). All 3 rural subtypes had a statistically significant decrease in the prevalence of low nutrient energy dense (LNED) vending items between 2006 and 2012, with the exception of sports drinks. However, different vending practices were observed between rural subtypes, with town/rural fringe schools providing more LNED vending options and experiencing less positive change over time compared to town/rural distant and remote rural schools. Differences in vending machine practices emerge when rural schools are subtyped.

Prevalence and Risk of Severe Cognitive Impairment in Advanced Chronic Kidney Disease.

Background: Our primary goal is to describe the prevalence, severity, and risk of cognitive impairment (CI) by estimated glomerular filtration rate (eGFR, in mL/min/1.73 m2) in a cohort enriched for advanced chronic kidney disease (CKD; eGFR < 45), adjusting for albuminuria, as measured by urine albumin-to-creatinine ratio (UACR, in mg/g). As both eGFR and albuminuria are associated with CI risk in CKD, we also seek to determine the extent that eGFR remains a useful biomarker for risk of CI in those with CKD and concomitant albuminuria. Methods: Chi-square tests measured the prevalence of severe CI and mild cognitive impairment (MCI) by eGFR level. Logistic regression models and generalized linear models measured risk of CI by eGFR, adjusted for UACR. Results: Participants were 574 adults with a mean age of 69; 433 with CKD (eGFR < 60, nondialysis) and 141 controls (eGFR ≥ 60). Forty-eight percent of participants with CKD had severe CI or MCI. The prevalence of severe CI was highest (25%) in those with eGFR < 30. eGFR < 30 was only associated with severe CI in those without albuminuria (UACR < 30; OR = 3.3; p = .02) and was not associated with MCI in similar models. Conclusions: One quarter of those with eGFR < 30 had severe CI. eGFR < 30 was associated with over threefold increased odds of severe CI in those with UACR < 30, but not with UACR > 30, suggesting that eGFR < 30 is a valid biomarker for increased risk of severe CI in those without concomitant albuminuria.

Disparities in Supports for Student Wellness Promotion Efforts Among Secondary Schools in Minnesota.

BACKGROUND: We examined whether there are differences in the presence of supports for student wellness promotion (1) between schools in city, suburban and rural locations and, (2) among rural schools, according to distance from a metropolitan center. METHODS: The analysis was conducted in a sample of 309 secondary schools using 2012 Minnesota School Health Profiles surveys and National Center for Educational Statistics Common Core Data. Scores for overall support addressed school health improvement coordination (range: 0-29), collaboration on health education activities (range: 0-5), and teachers' professional preparation (range: 0-7). RESULTS: Mean overall scores for health improvement coordination (10.5 ± 7.3), collaboration on health education activities (3.0 ± 1.5) and professional preparation (4.0 ± 1.9) indicated supports are lacking in schools across city, suburban, and rural locations. Comparison of overall scores did not identify disparities; however, weaknesses and strengths of particular relevance for rural schools were identified in examining specific aspects of support. For example, the proportion of rural schools having a written school improvement plan was 54.8% compared to 84.6% of city schools and 64.3% of suburban schools (p = .01). CONCLUSIONS: Tailored training and technical assistance are needed to better support schools in implementing recommended wellness policies and practices.

Association of Kidney Function Biomarkers with Brain MRI Findings: The BRINK Study.

BACKGROUND: Chronic kidney disease (CKD) studies have reported variable prevalence of brain pathologies, in part due to low inclusion of participants with moderate to severe CKD. OBJECTIVE: To measure the association between kidney function biomarkers and brain MRI findings in CKD. METHODS: In the BRINK (BRain IN Kidney Disease) study, MRI was used to measure gray matter volumes, cerebrovascular pathologies (white matter hyperintensity (WMH), infarctions, microhemorrhages), and microstructural changes using diffusion tensor imaging (DTI). We performed regression analyses with estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR) as primary predictors, and joint models that included both predictors, adjusted for vascular risk factors. RESULTS: We obtained 240 baseline MRI scans (150 CKD with eGFR <45 in ml/min/1.73 m2; 16 mild CKD: eGFR 45-59; 74 controls: eGFR≥60). Lower eGFR was associated with greater WMH burden, increased odds of cortical infarctions, and worsening diffusion changes throughout the brain. In eGFR models adjusted for UACR, only cortical infarction associations persisted. However, after adjusting for eGFR, higher UACR provided additional information related to temporal lobe atrophy, increased WMH, and whole brain microstructural changes as measured by increased DTI mean diffusivity. CONCLUSIONS: Biomarkers of kidney disease (eGFR and UACR) were associated with MRI brain changes, even after accounting for vascular risk factors. UACR adds unique additional information to eGFR regarding brain structural and diffusion biomarkers. There was a greater impact of kidney function biomarkers on cerebrovascular pathologies and microstructural brain changes, suggesting that cerebrovascular etiology may be the primary driver of cognitive impairment in CKD.

It Takes a Village: Promoting Parent and Family Education on Healthy Lifestyles for Minnesota Secondary Students.

BACKGROUND: This study examines school strategies to educate parents over time about physical activity and nutrition and how those strategies are related to adolescent health behaviors. METHODS: Data from the Minnesota School Health Profiles Lead Health Education Teacher survey (2008-2012) and the Minnesota Student Survey (MSS, 2013) included provisions for parent education about physical activity and nutrition and student physical activity and dietary intake behaviors. Analyses were performed using SAS, version 9.3. A generalized estimating equation (GEE) was used to examine changes over time in school policies. Adjusted linear regression models examined cross-sectional association between school policies (2012) and school-level mean student outcomes (2013). RESULTS: Parent education about physical activity and nutrition was constant over time, with the exception of a decrease in physical activity education in schools with low minority enrollment. There was a positive relationship between schools offering physical activity education for parents and the number of days a student meets physical activity and water consumption recommendations. There was no relationship between strategies for nutrition education and dietary intake. CONCLUSIONS: School providing strategies for parent engagement around student physical activity and nutrition may increase parent engagement overall and improve adolescent and school-related outcomes.

School-Based Obesity-Prevention Policies and Practices and Weight-Control Behaviors among Adolescents.

BACKGROUND: The promotion of healthy eating and physical activity within school settings is an important component of population-based strategies to prevent obesity; however, adolescents may be vulnerable to weight-related messages, as rapid development during this life stage often leads to preoccupation with body size and shape. OBJECTIVE: This study examines secular trends in secondary school curricula topics relevant to the prevention of unhealthy weight-control behaviors; describes cross-sectional associations between weight-related curricula content and students' use of weight-control behaviors; and assesses whether implementation of school-based obesity-prevention policies/practices is longitudinally related to students' weight-control behaviors. DESIGN: The Minnesota School Health Profiles and Minnesota Student Survey (grades 9 and 12) data were used along with National Center for Education Statistics data to examine secular trends, cross-sectional associations (n=141 schools), and longitudinal associations (n=42 schools). MAIN OUTCOME MEASURES: Students self-reported their height and weight along with past-year use of healthy (eg, exercise), unhealthy (eg, fasting), and extreme (eg, use laxatives) weight-control behaviors. STATISTICAL ANALYSES PERFORMED: Descriptive statistics, generalized estimating equations, and generalized linear regression models accounting for school-level demographics. RESULTS: There was no observable pattern during the years 2008 to 2014 in the mean number of curricula topics addressing unhealthy weight-control behaviors, despite an increase in the prevalence of curricula addressing acceptance of body-size differences. Including three vs fewer weight-control topics and specifically including the topic of eating disorders in the curricula was related to a lower school-level percent of students using any extreme weight-control behaviors. In contrast, an overall measure of implementing school-based obesity-prevention policies/practices (eg, prohibited advertising) was unrelated to use of unhealthy or extreme behaviors. CONCLUSIONS: Results suggest obesity-prevention policies/practices do not have unintended consequences for student weight-control behaviors and support the importance of school-based health education as part of efforts to prevent unhealthy behaviors.

Best Practices for Biostatistical Consultation and Collaboration in Academic Health Centers.

Given the increasing level and scope of biostatistics expertise needed at academic health centers today, we developed best practices guidelines for biostatistics units to be more effective in providing biostatistical support to their institutions, and in fostering an environment in which unit members can thrive professionally. Our recommendations focus on the key areas of: 1) funding sources and mechanisms; 2) providing and prioritizing access to biostatistical resources; and 3) interacting with investigators. We recommend that the leadership of biostatistics units negotiate for sufficient long-term infrastructure support to ensure stability and continuity of funding for personnel, align project budgets closely with actual level of biostatistical effort, devise and consistently apply strategies for prioritizing and tracking effort on studies, and clearly stipulate with investigators prior to project initiation policies regarding funding, lead time, and authorship.

Perceived barriers to success for resident physicians interested in immigrant and refugee health.

BACKGROUND: Cross-cultural care is recognized by the ACGME as an important aspect of US residency training. Resident physicians' preparedness to deliver cross-cultural care has been well studied, while preparedness to provide care specifically to immigrant and refugee populations has not been. METHODS: We administered a survey in October 2013 to 199 residents in Internal Medicine, Pediatrics, and Medicine/Pediatrics at the University of Minnesota, assessing perceived knowledge, attitudes, and experience with immigrant and refugee patients. RESULTS: Eighty-three of 199 residents enrolled in Internal Medicine, Pediatrics and Medicine/Pediatrics programs at the University of Minnesota completed the survey (42 %). Most (n = 68, 82 %) enjoyed caring for immigrants and refugees. 54 (65 %) planned to care for this population after residency, though 45 (54 %) were not comfortable with their knowledge regarding immigrant and refugee health. Specific challenges were language (n = 81, 98 %), cultural barriers (n = 76, 92 %), time constraints (n = 60, 72 %), and limited knowledge of tropical medicine (n = 57, 69 %). 67 (82 %) wanted more training in refugee and immigrant health. CONCLUSIONS: The majority of residents enjoyed caring for immigrant and refugee patients and planned to continue after residency. Despite favorable attitudes, residents identified many barriers to providing good care. Some involved cultural and language barriers, while others were structural. Finally, most respondents felt they needed more education, did not feel comfortable with their knowledge, and wanted more training during residency. These data suggest that residency programs consider increasing training in these specific areas of concern.

School Obesity Prevention Policies and Practices in Minnesota and Student Outcomes: A Longitudinal Cohort Study.

INTRODUCTION: The School Obesity-related Policy Evaluation (ScOPE) Study uses existing public surveillance data and applies a rigorous study design to evaluate effectiveness of school policies and practices impacting student behavioral and weight outcomes. METHODS: The ScOPE Study used a cohort of 50 combined junior-senior and high schools in Minnesota to evaluate the change in weight-related policy environments in 2006 and 2012 and test the effect of policy change on students attending those schools in 2007 and 2013. Exposure variables included school practices about foods and beverages available in school vending machines and school stores, physical education requirements, and intramural opportunities. Primary study outcomes were average school-level ninth grade student BMI percentile, obesity prevalence, daily servings of fruits/vegetables, and daily glasses of soda. RESULTS: Availability of fruits/vegetables in schools was associated with a significant increase in total daily intake among ninth grade students by 0.4 servings. Availability of soda in schools was associated with a significant increase in total daily intake among ninth grade boys by 0.5 servings. Less-healthy snack and drink availability in schools was associated with a small, significant increase (1%) in student BMI percentile at the school level. CONCLUSIONS: Use of a school-level longitudinal cohort study design over a 6-year period uniquely adds to the methodologic rigor of school policy and practice evaluation studies. The ScOPE Study provides marginal evidence that school policies and practices, especially those that restrict vending and school store offerings, may have small effects on weight status among ninth grade students.

School district wellness policy quality and weight-related outcomes among high school students in Minnesota.

Weight-related outcomes were examined among high school students in Minnesota public school districts according to the quality of district wellness policies. Wellness policy strength and comprehensiveness were scored using the Wellness School Assessment Tool (WellSAT) for 325 Minnesota public school districts in 2013. The associations between WellSAT scores and district-level means of high school student responses to a statewide survey of health behaviors were examined in this ecologic study. WellSAT Total Strength and Total Comprehensiveness scores were positively associated with both student mean Body Mass Index (BMI) percentile (Strength: P = 0.018, Comprehensiveness: P = 0.031) and mean percent overweight or obese (Strength: P = 0.008, Comprehensiveness: P = 0.026), but only in districts with > 50% of students eligible for Free or Reduced-Price Lunches (FRPLs), or 'high FRPL districts'. WellSAT Physical Education and Physical Activity subscale scores were also positively associated with the mean days per week students engaged in physical activity for ≥ 60 min in high FRPL districts (Strength: P = 0.008, Comprehensiveness: P = 0.003) and in low FRPL districts (< 35% eligible) for Strength score: (P = 0.027). In medium FRPL districts (35-50% eligible), Nutrition Education and Wellness Promotion Strength and Comprehensiveness subscale scores were positively associated with, respectively, daily servings of vegetables (P = 0.037) and fruit (P = 0.027); and WellSAT Total scores were positively associated with daily vegetable servings (Strength: P = 0.037, Comprehensiveness: P = 0.012). Administrators of economically disadvantaged school districts with a higher percentage of overweight students may be recognizing the need for stronger wellness policies and the specific importance of implementing policies pertaining to physical activity as a means to improve student health.

The Brain in Kidney Disease (BRINK) Cohort Study: Design and Baseline Cognitive Function.

BACKGROUND: The Brain in Kidney Disease (BRINK) Study aims to identify mechanisms that contribute to increased risk for cognitive impairment in patients with chronic kidney disease (CKD). We describe the rationale, design, and methods of the study and report baseline recruitment and cognitive function results. STUDY DESIGN: Longitudinal observational cohort study of the epidemiology of cognitive impairment in CKD. The primary aim is to characterize the association between (1) baseline and incident stroke, white matter disease, estimated glomerular filtration rate (eGFR), inflammation, microalbuminuria, and dialysis initiation and (2) cognitive decline over 3 years in a CKD cohort with a mean eGFR<45 mL/min/1.73 m(2). SETTING & PARTICIPANTS: Community-dwelling participants 45 years or older recruited from 4 health systems into 2 groups: reduced eGFR, defined as eGFR<60 mL/min/1.73 m(2) (non-dialysis dependent), and control, defined as eGFR≥60 mL/min/1.73 m(2). PREDICTOR: eGFR group. OUTCOMES: Performance on cognitive function tests and structural brain magnetic resonance imaging. MEASUREMENTS: Sequential cognitive and physical function testing, serum and urine biomarker measurement, and brain magnetic resonance images over 3 years. RESULTS: Of 554 participants, mean age was 69.3 years; 333, 88, and 133 had eGFRs<45 (non-dialysis dependent, nontransplantation), 45 to <60, and ≥60 (controls) mL/min/1.73 m(2), respectively. Mean eGFR in reduced-eGFR participants was 34.3 mL/min/1.73 m(2). Baseline cognitive performance was significantly associated with eGFR in all domains except language. Participants with eGFRs<30 mL/min/1.73 m(2) performed significantly worse than those with eGFRs≥30 mL/min/1.73 m(2) on tests of memory, processing speed, and executive function. Participants with reduced eGFRs overall scored worst on the Immediate Brief Visual-Spatial Memory Test-Revised. LIMITATIONS: Healthy cohort bias, competing risk for death versus cognitive decline. CONCLUSIONS: Cognitive function was significantly worse in participants with eGFRs<30 mL/min/1.73 m(2). Future BRINK analyses will measure risk factors for cognitive decline using the longitudinal data.

Concept Mapping as an Approach to Facilitate Participatory Intervention Building.

BACKGROUND: A challenge to addressing community-defined need through community-based participatory intervention building is ensuring that all collaborators' opinions are represented. Concept mapping integrates perspectives of individuals with differing experiences, interests, or expertise into a common visually depicted framework, and ranks composite views on importance and feasibility. OBJECTIVES: To describe the use of concept mapping to facilitate participatory intervention building for a school-based, teacher-focused, positive youth development (PYD) promotion program for Latino, Hmong, and Somali youth. Particiants were teachers, administrators, youth, parents, youth workers, and community and university researchers on the projects' community collaborative board. We incorporated previously collected qualitative data into the process. METHODS: In a mixed-methods process we 1) generated statements based on key informant interview and focus group data from youth workers, teachers, parents, and youth in multiple languages regarding ways teachers promote PYD for Somali, Latino and Hmong youth; 2) guided participants to individually sort statements into meaningful groupings and rate them by importance and feasibility; 3) mapped the statements based on their relation to each other using multivariate statistical analyses to identify concepts, and as a group identified labels for each concept; and 4) used labels and statement ratings to identify feasible and important concepts as priorities for intervention development. RESULTS: We identified 12 concepts related to PYD promotion in schools and prioritized 8 for intervention development. CONCLUSIONS: Concept mapping facilitated participatory intervention building by formally representing all participants' opinions, generating visual representation of group thinking, and supporting priority setting. Use of prior qualitative work increased the diversity of viewpoints represented.

A Tale of Two Community Networks Program Centers: Operationalizing and Assessing CBPR Principles and Evaluating Partnership Outcomes.

BACKGROUND: Community Networks Program (CNP) centers are required to use a community-based participatory research (CBPR) approach within their specific priority communities. Not all communities are the same and unique contextual factors and collaborators' priorities shape each CBPR partnership. There are also established CBPR and community engagement (CE) principles shown to lead to quality CBPR in any community. However, operationalizing and assessing CBPR principles and partnership outcomes to understand the conditions and processes in CBPR that lead to achieving program and project level goals is relatively new in the science of CBPR. OBJECTIVES: We sought to describe the development of surveys on adherence to and implementation of CBPR/CE principles at two CNP centers and examine commonalities and differences in program-versus project-level CBPR evaluation. METHODS: A case study about the development and application of CBPR/CE principles for the Missouri CNP, Program for the Elimination of Cancer Disparities, and Minnesota CNP, Padres Informados/Jovenes Preparados, surveys was conducted to compare project versus program operationalization of principles. Survey participant demographics were provided by CNP. Specific domains found in CBPR/CE principles were identified and organized under an existing framework to establish a common ground. Operational definitions and the number of survey items were provided for each domain by CNP. CONCLUSION: There are distinct differences in operational definitions of CBPR/CE principles at the program and project levels of evaluation. However, commonalities support further research to develop standards for CBPR evaluation across partnerships and at the program and project levels.