Federal Way, WA, United States
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Huang D.L.,University of Washington | Abrass I.B.,University of Washington | Young B.A.,Epidemiology Research and Information Center | Young B.A.,University of Washington
BMC Nephrology | Year: 2014

Background: Medication safety in patients with chronic kidney disease (CKD) is a growing concern. This is particularly relevant in older adults due to underlying CKD. Metformin use is contraindicated in patients with abnormal kidney function; however, many patients are potentially prescribed metformin inappropriately. We evaluated the prevalence of CKD among older adults prescribed metformin for type 2 diabetes mellitus using available equations to estimate kidney function and examined demographic characteristics of patients who were potentially inappropriately prescribed metformin. Methods. We conducted a cross-sectional analysis of older adults aged ≥65 years prescribed metformin from March 2008-March 2009 at an urban tertiary-care facility in Seattle, Washington, USA. CKD was defined using National Kidney Foundation-Kidney Disease Outcomes Quality Initiative criteria. Creatinine clearance was calculated using the Cockcroft-Gault equation; estimated glomerular filtration rate was calculated using the abbreviated Modification of Diet in Renal Disease (MDRD) and CKD-Epidemiology (EPI) Collaboration equations. Regression analyses were used to determine the associations between demographic characteristics and prevalent CKD. Results: Among 356 subjects (median age 69 years, 52.5% female, 39.4% non-Hispanic black), prevalence of stage 3 or greater CKD calculated by any of the equations was 31.4%. The Cockcroft-Gault equation identified more subjects as having CKD (23.7%) than the abbreviated MDRD (21.1%) or CKD-EPI (21.7%) equations (P < 0.001). Older age (OR = 1.13, 95% CI 1.08-1.19) and female sex (OR = 2.51, 95% CI 1.44-4.38) were associated with increased odds of potentially inappropriate metformin prescription due to CKD; non-Hispanic black race was associated with decreased odds of potentially inappropriate metformin prescription due to CKD (OR = 0.41, 95% CI 0.23-0.71). Conclusions: CKD is common in older adults prescribed metformin for type 2 diabetes, raising concern for potentially inappropriate medication use. No single equation to estimate kidney function may accurately identify CKD in this population. Medication safety deserves greater consideration among elderly patients due to the widespread prevalence of CKD. © 2014 Huang et al.; licensee BioMed Central Ltd.


Williams E.C.,Health Services Research and Development HSR and D | Williams E.C.,Veterans Affairs VA Puget Sound Health Care System | Williams E.C.,University of Washington | Lapham G.T.,Health Services Research and Development HSR and D | And 17 more authors.
Alcoholism: Clinical and Experimental Research | Year: 2012

Background: The VA Healthcare System has made progress implementing evidence-based care for unhealthy alcohol use, but whether there are differences in care across race/ethnicity is unclear. We describe alcohol-related care for 3 racial/ethnic groups among VA outpatients with unhealthy alcohol use. Methods: This cross-sectional study utilized secondary quality improvement data collected for the VA Office of Quality and Performance (July 2006 to June 2007) to identify a sample of 9,194 black (n = 1,436), Hispanic (n = 500), and white (n = 7,258) VA outpatients who screened positive for unhealthy alcohol use (AUDIT-C score ≥4 men; ≥3 women). Alcohol-related care was defined as medical record documentation of brief intervention (advice or feedback) and/or referral (discussion of or scheduled). Logistic regression models estimated the prevalence of alcohol-related care among black, Hispanic, and white patients after adjustment for sociodemographic characteristics, alcohol use severity, other substance use, and mental health comorbidity. Results: Among all eligible patients, 2,903 (32%) had documented alcohol-related care. Adjusted prevalences were 35.3% (95% CI 30.0 to 40.5) for black, 27.3% (95% CI 21.1 to 33.5) for Hispanic, and 28.9% (95% CI 25.5 to 32.3) for white patients. Differences in documented alcohol-related care between all racial/ethnic groups were significant (p-values all < 0.05). Conclusions: Among VA patients with unhealthy alcohol use, black patients had the highest, and Hispanic the lowest, prevalence of documented alcohol-related care. Future research should evaluate contextual and system-, provider-, or patient-level factors that may attenuate racial/ethnic differences in documented alcohol-related care, as well as whether differences in documented care are associated with differences in outcomes. © 2012 by the Research Society on Alcoholism.


Fang F.,U.S. National Institutes of Health | Fang F.,Karolinska Institutet | Kwee L.C.,Duke University | Kwee L.C.,Epidemiology Research and Information Center | And 11 more authors.
American Journal of Epidemiology | Year: 2010

The authors conducted a 2003-2007 case-control study including 184 cases and 194 controls to examine the association between blood lead and the risk of amyotrophic lateral sclerosis (ALS) among US veterans and to explore the influence on this association of bone turnover and genetic factors related to lead toxicokinetics. Blood lead, plasma biomarkers of bone formation (procollagen type 1 amino-terminal peptide (PINP)) and resorption (C-terminal telopeptides of type 1 collagen (CTX)), and the K59N polymorphism in the δ-aminolevulinic acid dehydratase gene, ALAD, were measured. Odds ratios and 95% confidence intervals for the association of blood lead with ALS were estimated with unconditional logistic regression after adjustment for age and bone turnover. Blood lead levels were higher among cases compared with controls (P < 0.0001, age adjusted). A doubling of blood lead was associated with a 1.9-fold increased risk of ALS (95% confidence interval: 1.3, 2.7) after adjustment for age and CTX. Additional adjustment for PINP did not alter the results. Significant lead-ALS associations were observed in substrata of PINP and CTX levels. The K59N polymorphism in the ALAD gene did not modify the lead-ALS association (P = 0.32). These results extend earlier findings by accounting for bone turnover in confirming the association between elevated blood lead level and higher risk of ALS. © 2010 The Author.


Yu M.K.,University of Washington | Yu M.K.,Kidney Research Institute | Lyles C.R.,University of Washington | Lyles C.R.,University of California at San Francisco | And 5 more authors.
Journal of Diabetes Research | Year: 2013

Patients with chronic diabetic complications experience high morbidity and mortality. Sex disparities in modifiable factors such as processes of care or self-care activities have not been explored in detail, particularly in these high-risk patients. Sex differences in processes of care and self-care activities were assessed in a cross-sectional analysis of the Pathways Study, an observational cohort of primary care diabetic patients from a managed care organization (N = 4,839). Compared to men, women had decreased odds of dyslipidemia screening (adjusted odds ratio (AOR) 0.73, 95% CI 0.62-0.85), reaching low-density lipoprotein goal (AOR 0.70, 95% CI 0.58-0.86), and statin use (AOR 0.69, 95% CI 0.58-0.81); women had 19% greater odds of reaching hemoglobin A1c <7% (95% CI 1.02-1.41). There were no sex differences in hemoglobin A1c testing, microalbuminuria screening, or angiotensin-converting enzyme inhibitor use. Women were less likely to report regular exercise but had better adherence to healthy diet, glucose monitoring, and self-foot examination compared to men. Patterns of sex differences were consistent in subjects with diabetic complications. Significant sex disparities exist in diabetes process of care measures and self-care, even amongst patients known to have chronic diabetic complications. © 2013 Margaret K. Yu et al.


Schmidt S.,Duke University | Schmidt S.,Epidemiology Research and Information Center | Kwee L.C.,Duke University | Kwee L.C.,Epidemiology Research and Information Center | And 4 more authors.
Journal of the Neurological Sciences | Year: 2010

Objective: An increased risk of ALS has been reported for US veterans, but the cause is unknown. Since head injury and cigarette smoking are two previously implicated environmental risk factors that are more common in military than civilian study populations, we tested their association with ALS in a US veteran study population. Methods: We used logistic regression to examine the association of ALS with head injury and cigarette smoking in 241 incident cases and 597 controls. Since APOE is a plausible ALS candidate gene, we also tested its main effect and its statistical interaction with these environmental exposures. Results: Cigarette smoking was not associated with ALS in this predominantly male and Caucasian population. Veterans who had experienced head injuries during the last 15 years before the reference date had an adjusted odds ratio of 2.33 (95% confidence interval 1.18-4.61), relative to veterans without any head injuries. This association was strongest in APOE-4 carriers. Conclusions: Our results add to the body of evidence suggesting that head injuries may be a risk factor for multiple neurodegenerative diseases, including ALS. We hypothesize that the strength of association between head injuries and ALS may depend upon APOE genotype. © 2010 Elsevier B.V.


Yu M.K.,University of Washington | Yu M.K.,Kidney Research Institute | Lyles C.R.,University of Washington | Bent-Shaw L.A.,University of Washington | And 3 more authors.
American Journal of Nephrology | Year: 2012

Background/Aims: Women with diabetes experience a disproportionately greater burden of diabetic kidney disease (DKD) risk factors compared to men; however, sex-specific differences in DKD are not well defined. The effect of age on sex differences in DKD is unknown. Methods: We performed a cross-sectional analysis of the prevalence of DKD (eGFR <60 ml/min/1.73 m2 or microalbuminuria), advanced DKD (eGFR <30 ml/min/1.73 m2), and common DKD risk factors in the Pathways Study (n = 4,839), a prospective cohort study of diabetic patients from a managed care setting. Subjects were stratified by age <60 and ≥60 years to examine for differences by age. Logistic regression models examined the association between sex and prevalence of DKD and risk factors. Results: Women of all ages had 28% decreased odds of DKD (OR 0.72, 95% CI 0.62-0.83); however, they had a greater prevalence of advanced DKD (OR 1.67, 95% CI 1.05-2.64), dyslipidemia (OR 1.42, 95% CI 1.16-1.74), and obesity (OR 1.87, 95% CI 1.60-2.20) compared to men. Women had similar odds of hypertension and poor glycemic control as men. Women ≥60 years had increased odds of advanced DKD, hypertension, dyslipidemia, and obesity compared to similarly aged men. Women <60 years had increased odds of obesity compared to their male counterparts. Conclusion: Women with diabetes had an increased prevalence of advanced DKD and common DKD risk factors compared to men and these disparities were most prominent amongst the elderly. Copyright © 2012 S. Karger AG, Basel.


Kwee L.C.,Epidemiology Research and Information Center | Kwee L.C.,Duke University | Liu Y.,Epidemiology Research and Information Center | Liu Y.,Duke University | And 21 more authors.
PLoS ONE | Year: 2012

Following reports of an increased incidence of amyotrophic lateral sclerosis (ALS) in U.S. veterans, we have conducted a high-density genome-wide association study (GWAS) of ALS outcome and survival time in a sample of U.S. veterans. We tested ~1.3 million single nucleotide polymorphisms (SNPs) for association with ALS outcome in 442 incident Caucasian veteran cases diagnosed with definite or probable ALS and 348 Caucasian veteran controls. To increase power, we also included genotypes from 5909 publicly-available non-veteran controls in the analysis. In the survival analysis, we tested for association between SNPs and post-diagnosis survival time in 639 Caucasian veteran cases with definite or probable ALS. After this discovery phase, we performed follow-up genotyping of 299 SNPs in an independent replication sample of Caucasian veterans and non-veterans (ALS outcome: 183 cases and 961 controls; survival: 118 cases). Although no SNPs reached genome-wide significance in the discovery phase for either phenotype, three SNPs were statistically significant in the replication analysis of ALS outcome: rs6080539 (177 kb from PCSK2), rs7000234 (4 kb from ZNF704), and rs3113494 (13 kb from LOC100506746). Two SNPs located in genes that were implicated by previous GWA studies of ALS were marginally significant in the pooled analysis of discovery and replication samples: rs17174381 in DPP6 (p = 4.4×10 -4) and rs6985069 near ELP3 (p = 4.8×10 -4). Our results underscore the difficulty of identifying and convincingly replicating genetic associations with a rare and genetically heterogeneous disorder such as ALS, and suggest that common SNPs are unlikely to account for a substantial proportion of patients affected by this devastating disorder.


Jimenez N.,University of Washington | Dansie E.,University of Washington | Buchwald D.,University of Washington | Goldberg J.,University of Washington | Goldberg J.,Epidemiology Research and Information Center
Pain Medicine (United States) | Year: 2013

Background: Previous studies suggest that acculturation may influence the experience of pain. Study Design: We conducted a cross-sectional study to estimate the association between acculturation and the prevalence, intensity, and functional limitations of pain in older Hispanic adults in the United States. Methods Subjects: Participants were English- (HE) and Spanish-speaking (HS) Hispanic and non-Hispanic White (NHW) individuals aged 50 years and older who were interviewed for the Health and Retirement Study during 1998-2008. Measures: We measured: 1) acculturation as defined by language used in interviews, and 2) the presence, intensity, and functional limitations of pain. Analysis: We applied logistic regression using generalized estimating equations, with NHW as the reference category. Results: Among 18,593 participants (16,733 NHW, 824 HE, and 1,036 HS), HS had the highest prevalence (odds ratio [OR]=1.3; 95% confidence interval [CI=1.1-1.4) and intensity (OR=1.6; 95% CI=1.4-1.9) of pain, but these differences were not significant after adjusting for age, sex, years of education, immigration status (U.S.- vs non-U.S-born), and health status (number of health conditions). Even after adjustment, HS reported the lowest levels of functional limitation (OR=0.7; 95% CI 0.6-0.9). Conclusion: Pain prevalence and intensity were not related to acculturation after adjusting for sociodemographic factors, while functional limitation was significantly lower among HS even after adjusting for known risk factors. Future studies should explore the reasons for this difference. © 2013 American Academy of Pain Medicine Wiley Periodicals, Inc.

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