A unified framework for assessing interaction effects among environmental exposures in epidemiologic studies: A case study on temperature, air pollution, and kidney-related conditions in New York state.

BACKGROUND: There are various methods to assess interaction effects. However, current methods have limitations, and quantification of interaction effects is rarely performed. This study aimed to develop a unified quantitative framework for assessing interaction effects. METHODS: We proposed a novel framework using log-linear models with a product term(s) across the exposures that generates parametric bi-variate association and interaction effect surfaces and allows flexible functional forms for exposures in the interaction term(s). In a case study, we assessed the interaction effects between temperature and air pollution (i.e., PM2.5, NO2, and O3) on risk for kidney-related conditions in New York State (2007-2016) using a case-crossover design with conditional logistic models. Our measures of exposure were the moving averages at lag 0-5 days for air pollution (linear) and daytime mean outdoor wet-bulb globe temperature (WBGT; using a natural cubic spline). RESULTS: We derived closed-form expressions for the magnitude of multiplicative interaction effects (the joint relative risk divided by the product of the two conditional relative risks) and their uncertainties. In the case study, we found a Bonferroni-corrected significant multiplicative interaction effect (IE) between outdoor WBGT at the 99th percentile (median as the reference) and (1) PM2.5 (per 5 µg/m3 increase, IE = 1.052; 95 % confidence interval [CI]: 1.019, 1.087) for acute kidney failure and (2) O3 (per 5 ppb increase; IE = 1.022; 95 % CI: 1.008, 1.036) for urolithiasis (the latter being inconclusive based on the sensitivity analysis). CONCLUSIONS: Our framework allows different functional forms of exposure variables in the interaction term, quantifies the magnitudes of entire-exposure-range (in addition to discrete exposure level) multiplicative interaction effects and their uncertainties in a categorical or continuous (linear or non-linear) manner, and harmonizes the two-way evaluation of effect modification. The case study underscores co-consideration of heat and air pollution when estimating health burden and designing heat/pollution alert systems.

Serum Creatinine-to-Cystatin-C Ratio as a Potential Muscle Mass Surrogate and Racial Differences in Mortality.

OBJECTIVES: Serum creatinine-based estimated glomerular filtration rate equations and muscle mass are powerful markers of health and mortality risk. However, the serum creatinine-to-cystatin-C ratio may be a better indicator of health status. The objective of this study was to describe the relationship between creatinine-to-cystatin-C ratio and all-cause mortality when stratifying patients as per race and as per chronic kidney disease status. METHODS: This was a retrospective cohort study examining black and nonblack US veterans between October 2004 and September 2019, with baseline cystatin C and creatinine data from those not on dialysis during the study period. Veterans were divided into four creatinine-to-cystatin-C ratio groups: <0.75, 0.75-<1.00, 1.0-<1.25, and ≥1.25. The primary outcome of interest was all-cause mortality subsequent to the cystatin C laboratory measure. RESULTS: Among 22,316 US veterans, the mean (± standard deviation) age of the cohort was 67 ± 14 years, 5% were female, 82% were nonblack, and 18% were black. The proportion of black veterans increased across creatinine-to-cystatin-C ratio groups. In the fully adjusted model, compared with the reference (creatinine-to-cystatin-C ratio: 1.00-<1.25), a creatinine-to-cystatin-C ratio <0.75 had the highest mortality risk among both black and nonblack veterans (nonblack: hazard ratio [HR] [95% confidence interval {CI}]: 3.01 [2.78-3.26] and black: 4.17 [3.31-5.24]). A creatinine-to-cystatin-ratio ≥1.25 was associated with lower death risk than the referent in both groups (nonblack: HR [95% CI]: 0.89 [0.80-0.99] and black: HR [95% CI]: 0.55 [0.45-0.69]). However, there was a significant difference in the effect by race (Wald's P-value: <0.01). CONCLUSIONS: Higher creatinine-to-cystatin-C ratios indicate better health status and are strongly associated with lower mortality risk regardless of the kidney function level, and the relation was similar for both black and nonblack veterans, but with different strengths of effect across racial groups. Thereby, use of a fixed race coefficient in estimating kidney function may be biased.

Relationships between short-term ambient temperature exposure and kidney disease hospitalizations in the warm season in Vietnam: A case-crossover study.

BACKGROUND: Under a warming climate, adverse health effects of heat are an increasing concern. We evaluated associations between short-term ambient temperature exposure and hospital admission for kidney disease in Vietnam. METHODS: We linked province-level meteorologic data with admission data from 14 province-level hospitals (2003-2015). We used a case-crossover design to evaluate associations between daily ambient temperature metrics (mean, maximum, and minimum temperature and mean heat index) and risk of hospitalization for four kidney disease subtypes: glomerular diseases, renal tubulo-interstitial diseases, chronic kidney disease, and urolithiasis, including lagged (≤lag 14 days) and cumulative (≤lag 0-6 days) associations, during the warm season. We also evaluated independent associations with extreme heat days (defined as days with daily maximum temperature >95th percentile of the provincial daily maximum temperature distribution). Akaike's information criterion and patterns of risk estimates across cumulative exposure time windows and single-day lags informed our selection of final models. RESULTS: We included 58,330 hospital admissions during the warm season. Daily mean temperature averaged over the same day and the previous six days (lag 0-6 days) was associated with risk of hospitalization for each kidney disease outcome with odds ratios (per 1 °C increase in daily mean temperature) of 1.07 (95% confidence interval [CI]: 0.99, 1.16) for glomerular diseases, 1.06 (95% CI: 0.96, 1.17) for renal tubulo-interstitial diseases, 1.12 (95% CI: 1.00, 1.24) for chronic kidney disease, and 1.09 (95% CI: 1.02, 1.16) for urolithiasis. We found no additional independent associations with extreme heat. Results for the four temperature metrics were similar. CONCLUSIONS: High ambient temperature was associated with increased risk of hospitalization for each kidney disease subtype, with the most convincing associations for chronic kidney disease and urolithiasis. Further laboratory and epidemiologic research is needed to confirm the findings and disentangle the underlying mechanisms.

Burden and Cost of Caring for US Veterans With CKD: Initial Findings From the VA Renal Information System (VA-REINS).

Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.

The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units.

BACKGROUND: Outpatient dialysis is standardized with several evidence-based measures of adequacy and quality that providers aim to meet while providing treatment. By contrast, in the intensive care unit (ICU) there are different types of prolonged and continuous renal replacement therapies (PIRRT and CRRT, respectively) with varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. To eventually describe appropriate quality measures for ICU-related renal replacement therapy (RRT), we first aimed to capture the variety and prevalence of basic strategies and equipment utilized in the ICUs of Veteran Affairs (VA) medical facilities with inpatient hemodialysis capabilities. METHODS: Via email to the dialysis directors of all VA facilities that provided inpatient hemodialysis during 2018, we requested survey participation regarding aspects of RRT in VA ICUs. Questions centered around the mode of therapy, equipment, solutions, prescription authority, nursing, anticoagulation, antimicrobial dosing, and access. RESULTS: Seventy-six centers completed the questionnaire, achieving a response rate of 87.4%. Fifty-five centers reported using PIRRT or CRRT in addition to intermittent hemodialysis. Of these centers, 42 reported being specifically CRRT-capable. Over half of respondents had the capabilities to perform PIRRT. Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was largely prescribed by nephrologists (94.4% of centers). CONCLUSIONS: Within the VA system, ICU-related RRT practice is quite varied. Variation in processes of care, prescription authority, nursing care coordination, medication management, and safety practices present opportunities for developing cross-cutting measures of quality of intensive care RRT that are agnostic of modality choice.

Predictors of improvement in a family-based partial hospitalization/intensive outpatient program for eating disorders.

The efficacy of family-based treatment (FBT) in outpatient settings has led to efforts to incorporate FBT principles into higher levels of care. The present study examined predictors of improvement in an FBT-based partial hospitalization program/intensive outpatient program (PHP/IOP) as measured by the Eating Disorder Examination-Questionnaire. Participants were 113 patients with anorexia nervosa (AN) or eating disorder not otherwise specified (EDNOS) consecutively participating in an FBT-based PHP/IOP. Multilevel modeling was used to investigate predictors for adolescents and young adults separately. Predictors considered included illness duration, previous hospitalization, hospitalization immediately prior to treatment, previous outpatient therapy, hospitalization during treatment, diagnosis, gaining 4 pounds in 4 weeks, and family status as time-invariant variables. Time-varying variables considered included depression symptoms and mothers'/fathers' ratings of parental self-efficacy and expressed emotion. For adolescents, depression by time and diagnosis by time interactions were statistically significant. At all levels of depression, adolescent patients with AN demonstrated greater reductions in eating disorder symptoms compared to patients with EDNOS. For young adults, depression and gaining 4 pounds in 4 weeks were significant predictors. The relationships for young adults were curvilinear such that, while lower eating disorder symptoms were found during treatment, these gains were not maintained at follow up.

Development, implementation and user experience of the Veterans Health Administration (VHA) dialysis dashboard.

BACKGROUND: Adults with end-stage renal disease (ESRD) requiring chronic dialysis continue to suffer from poor health outcomes and represent a population rightfully targeted for quality improvement. Electronic dashboards are increasingly used in healthcare to facilitate quality measurement and improvement. However, detailed descriptions of the creation of healthcare dashboards are uncommonly available and formal inquiry into perceptions, satisfaction, and utility by clinical users has been rarely conducted, particularly in the context of dialysis care. Therefore, we characterized the development, implementation and user experience with Veterans Health Administration (VHA) dialysis dashboard. METHODS: A clinical-quality dialysis dashboard was implemented, which displays clinical performance measures (CPMs) for Veterans with ESRD receiving chronic hemodialysis at all VHA facilities. Data on user experience and perceptions were collected via an e-mail questionnaire to dialysis medical directors and nurse managers at these facilities. RESULTS: Since 2016 the dialysis dashboard reports monthly on CPMs for approximately 3000 Veterans receiving chronic hemodialysis across 70 VHA dialysis facilities. Of 141 dialysis medical directors and nurse managers, 61 completed the questionnaire. Sixty-six percent of respondents did not find the dashboard difficult to access, 64% agreed that it is easy to use, 59% agreed that its layout is good, and the majority agreed that presentation of data is clear (54%), accurate (56%), and up-to-date (54%). Forty-eight percent of respondents indicated that it helped them improve patient care while 12% did not. Respondents indicated that they used the dialysis dashboard for clinical reporting (71%), quality assessment/performance improvement (QAPI) (62%), and decision-making (23%). CONCLUSIONS: Most users of the VHA dialysis dashboard found it accurate, up-to-date, easy to use, and helpful in improving patient care. It meets diverse user needs, including administrative reporting, clinical benchmarking and decision-making, and quality assurance and performance improvement (QAPI) activities. Moreover, the VHA dialysis dashboard affords national-, regional- and facility-level assessments of quality of care, guides and motivates best clinical practices, targets QAPI efforts, and informs and promotes population health management improvement efforts for Veterans receiving chronic hemodialysis.

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings.

BACKGROUND: Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. METHODS: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. RESULTS: Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings. CONCLUSIONS: Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

Motivation for sport participation and eating disorder risk among female collegiate athletes.

In light of conflicting research regarding eating disorder risk and sports participation, the current study examined the relationship between specific aspects of sports participation (i.e., level of competition, leanness requirements, and physical/cardiovascular intensity level), an individual's motivation for sports participation, and eating disorder symptomatology/risk. Participants included 319 female collegiate athletes (M age = 19.88; SD = 1.62) representing a variety of sports and competition levels. Multilevel modeling found that level of competition, receiving a scholarship, age, and years of collegiate sport played did not predict eating disorder risk. In the final model, there was a significant interaction between intrinsic motivation and sport intensity. For high intensity sports, higher levels of intrinsic motivation were associated with lower eating disorder risk. For low intensity sports, the level of intrinsic motivation did not impact eating disorder risk. For all sport intensities, extrinsic motivation was associated with a higher eating disorder risk. Results suggest that it is not the specific sport but athletes' motivation for those sports with high physical/cardiovascular intensity and leanness requirements that is associated with untoward consequences. The results clarify conflicting results previously reported in the literature that have primarily employed univariate analyses and have implications for athletic development programs.

Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration.

Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.

Plasma Biomarkers and Kidney Function Decline in Early and Established Diabetic Kidney Disease.

Biomarkers of diverse pathophysiologic mechanisms may improve risk stratification for incident or progressive diabetic kidney disease (DKD) in persons with type 2 diabetes. To evaluate such biomarkers, we performed a nested case-control study (n=190 cases of incident DKD and 190 matched controls) and a prospective cohort study (n=1156) using banked baseline plasma samples from participants of randomized, controlled trials of early (ACCORD) and advanced (VA NEPHRON-D) DKD. We assessed the association and discrimination obtained with baseline levels of plasma TNF receptor-1 (TNFR-1), TNFR-2, and kidney injury molecule-1 (KIM-1) for the outcomes of incident DKD (ACCORD) and progressive DKD (VA-NEPHRON-D). At baseline, median concentrations of TNFR-1, TNFR-2, and KIM-1 were roughly two-fold higher in the advanced DKD population (NEPHRON-D) than in the early DKD population (ACCORD). In both cohorts, patients who reached the renal outcome had higher baseline levels than those who did not reach the outcome. Associations between doubling in TNFR-1, TNFR-2, and KIM-1 levels and risk of the renal outcomes were significant for both cohorts. Inclusion of these biomarkers in clinical models increased the area under the curve (SEM) for predicting the renal outcome from 0.68 (0.02) to 0.75 (0.02) in NEPHRON-D. Systematic review of the literature illustrated high consistency in the association between these biomarkers of inflammation and renal outcomes in DKD. In conclusion, TNFR-1, TNFR-2, and KIM-1 independently associated with higher risk of eGFR decline in persons with early or advanced DKD. Moreover, addition of these biomarkers to clinical prognostic models significantly improved discrimination for the renal outcome.

Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease.

Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center "Transition-of-Care-in-CKD" suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared with the non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen might preserve RKF, prolong vascular access longevity, improve patients' quality of life, and be a more patient-centered approach, more consistent with "personalized" dialysis. Broad implementation of incremental dialysis might also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are needed to examine the safety and efficacy of incremental hemodialysis in Veterans and other populations; the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.

North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease.

Whereas in many parts of the world a low protein diet (LPD, 0.6-0.8 g/kg/day) is routinely prescribed for the management of patients with non-dialysis-dependent chronic kidney disease (CKD), this practice is infrequent in North America. The historical underpinnings related to LPD in the USA including the non-conclusive results of the Modification of Diet in Renal Disease Study may have played a role. Overall trends to initiate dialysis earlier in the course of CKD in the US allowed less time for LPD prescription. The usual dietary intake in the US includes high dietary protein content, which is in sharp contradistinction to that of a LPD. The fear of engendering or worsening protein-energy wasting may be an important handicap as suggested by a pilot survey of US nephrologists; nevertheless, there is also potential interest and enthusiasm in gaining further insight regarding LPD's utility in both research and in practice. Racial/ethnic disparities in the US and patients' adherence are additional challenges. Adherence should be monitored by well-trained dietitians by means of both dietary assessment techniques and 24-h urine collections to estimate dietary protein intake using urinary urea nitrogen (UUN). While keto-analogues are not currently available in the USA, there are other oral nutritional supplements for the provision of high-biologic-value proteins along with dietary energy intake of 30-35 Cal/kg/day available. Different treatment strategies related to dietary intake may help circumvent the protein- energy wasting apprehension and offer novel conservative approaches for CKD management in North America.

ESRD care within the US Department of Veterans Affairs: a forward-looking program with an illuminating past.

The first governmental agency to provide maintenance hemodialysis to patients with end-stage renal disease (ESRD) was the Veterans Administration (VA; now the US Department of Veterans Affairs). Many historical VA policies and programs set the stage for the later care of both veteran and civilian patients with ESRD. More recent VA initiatives that target restructuring of care models based on quality management, system-wide payment policies to promote cost-effective dialysis, and innovation grants aim to improve contemporary care. The VA currently supports an expanded and diversified nationwide treatment program for patients with ESRD using an integrated patient-centered care paradigm. This narrative review of ESRD care by the VA explores not only the medical advances, but also the historical, socioeconomic, ethical, and political forces related to the care of veterans with ESRD.

Marine Pseudovibrio sp. as a novel source of antimicrobials.

Antibiotic resistance among pathogenic microorganisms is becoming ever more common. Unfortunately, the development of new antibiotics which may combat resistance has decreased. Recently, however the oceans and the marine animals that reside there have received increased attention as a potential source for natural product discovery. Many marine eukaryotes interact and form close associations with microorganisms that inhabit their surfaces, many of which can inhibit the attachment, growth or survival of competitor species. It is the bioactive compounds responsible for the inhibition that is of interest to researchers on the hunt for novel bioactives. The genus Pseudovibrio has been repeatedly identified from the bacterial communities isolated from marine surfaces. In addition, antimicrobial activity assays have demonstrated significant antimicrobial producing capabilities throughout the genus. This review will describe the potency, spectrum and possible novelty of the compounds produced by these bacteria, while highlighting the capacity for this genus to produce natural antimicrobial compounds which could be employed to control undesirable bacteria in the healthcare and food production sectors.

The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis.

The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.

Use of a computerized order set to increase prescription of calcium and vitamin D supplementation in patients receiving glucocorticoids.

BACKGROUND: American College of Rheumatology guidelines recommend that patients taking glucocorticoids also take calcium and vitamin D supplements, regardless of the dose or intended duration of glucocorticoid use, to decrease their risk of glucocorticoid-induced osteopenia or osteoporosis (GIOP). OBJECTIVE: To increase the number of prescriptions made for calcium and vitamin D in patients who receive a prescription for glucocorticoids using an automated, computerized order set. DESIGN: Pre-post test design. PATIENTS: A total of 1,041 outpatients receiving care at a single VA medical center. INTERVENTION/MAIN MEASURES: We developed an automated order set in which calcium and vitamin D were automatically co-ordered with glucocorticoid prescriptions of at least 2-week duration. We tested the impact of the order set by comparing the number of calcium and vitamin D prescriptions in patients taking glucocorticoids during a 12-month period before (T1) and after (T2) implementation. The automated order set could be modified by the treating physician, and it was not generated for patients with hypercalcemia. KEY RESULTS: A total of 535 patients during T1 and 506 patients during T2 had a glucocorticoid prescription of at least 2-week duration. The percent of co-prescriptions for calcium increased from 37 to 49% and vitamin D from 38 to 53% (both p < 0.0001) after the new automated order set was implemented. CONCLUSIONS: Implementation of an automatic prescription for calcium and vitamin D supplementation modestly increases the number of patients on glucocorticoids who are prescribed calcium and vitamin D supplementation.

Assessment of sleep problems in preschool aged children: an adaptation of the children's sleep habits questionnaire.

The purpose of the present study was to evaluate the factor structure of the children's sleep habits questionnaire (CSHQ) when used with preschool and toddler age children. Mothers of 105 children ages 2-5 completed the CSHQ, the child behavior checklist (CBCL), and a sleep diary. Internal consistency for the original subscales on the CSHQ ranged from .55 to .82 and factor analysis resulted in four factors that tap into critical aspects of sleep. The concurrent validity of the revised scales of the CSHQ was adequate. Overall the results from this study suggest a revised factor structure may be more appropriate for use with preschool and toddler age children.