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Memphis, TN, United States

Young J.C.,Memphis Veterans Affairs Medical Center | Gross A.M.,University of Mississippi
Archives of Clinical Neuropsychology | Year: 2011

Adults with attention-deficit/hyperactivity disorder (ADHD) are frequently prescribed stimulant medication and eligible for accommodations at work or school that serve as potent incentives to feign ADHD symptoms. The current investigation examined the predictive validity of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) validity scales in detecting and accurately classifying individuals attempting to feign ADHD. An archival ADHD clinical group (n = 34), normal control group (n = 37), and group instructed to feign ADHD symptoms (n = 32) completed the MMPI-2 and ADHD Current and Childhood Symptoms Scales. Behavior rating scales were unable to differentiate the clinical group from the simulated malingering group. Logistic regressions revealed that Infrequency-Psychopathology scale best detected response bias, followed by Infrequency scale, Back-Infrequency scale, Response Bias Scale (RBS), Henry-Heilbronner Index scale (HHI), and Fake Bad Scale (FBS). Results also indicate that recommended cutoffs for HHI, RBS, and FBS display inadequate sensitivity and specificity. Nevertheless, the MMPI-2 offers a number of validity indices that may assist in detecting individuals attempting to feign ADHD. © The Author 2011..

Kovesdy C.P.,University of Tennessee Health Science Center | Kovesdy C.P.,Memphis Veterans Affairs Medical Center
Kidney International Supplements | Year: 2016

Hyperkalemia represents one of the most important acute electrolyte abnormalities, due to its potential for causing life-threatening arrhythmias. In individuals with normal kidney function hyperkalemia occurs relatively infrequently, but it can be much more common in patients who have certain predisposing conditions. Patients with chronic kidney disease are the most severely affected group, by virtue of their decreased ability to excrete potassium and because they commonly have additional predisposing conditions that often cluster within patients with chronic kidney disease. These conditions include comorbidities (e.g., diabetes mellitus) and the use of various medications, of which the most important are renin-angiotensin-aldosterone system inhibitors (RAASis). Hyperkalemia is associated with increased risk for all-cause mortality and for malignant arrhythmias such as ventricular fibrillation. The increased risk for adverse outcomes is observed even in serum potassium ranges that are often not considered targets for therapeutic interventions. The heightened risk of mortality associated with hyperkalemia is present in all patient populations, even those in whom hyperkalemia occurs otherwise rarely, such as individuals with normal kidney function.

Kovesdy C.P.,Memphis Veterans Affairs Medical Center | Kovesdy C.P.,University of Tennessee Health Science Center | Lott E.H.,Veterans Affairs Informatics and Computing Infrastructure | Lu J.L.,University of Tennessee Health Science Center | And 7 more authors.
Journal of the American College of Cardiology | Year: 2013

Objectives: This study sought to compare the association of microalbuminuria with outcomes in patients with different comorbidities. Background: The risk of adverse outcomes associated with lower levels proteinuria has been found to be linearly decreasing with even low-normal levels of microalbuminuria. It is unclear whether comorbid conditions change these associations. Methods: We examined the association of urine microalbumin- creatinine ratio (UACR) with mortality and the slopes of estimated glomerular filtration rate (eGFR) in a nationally representative cohort of 298,875 U.S. veterans. Associations of UACR with all-cause mortality overall and in subgroups of patients with and without diabetes mellitus, hypertension, cardiovascular disease, congestive heart failure, and advanced chronic kidney disease (CKD) were examined in Cox models, and with the slopes of eGFR in linear and logistic regression models. Results: Very low levels of UACR were linearly associated with decreased mortality and less progression of CKD overall: adjusted mortality hazard ratio and estimated glomerular filtration rate slope (95% confidence interval [CI]) associated with UACR ≥200 μg/mg, compared to <5 μg/mg were 1.53 (95% CI: 1.38 to 1.69, p < 0.001) and -1.59 (95% CI: -1.83 to -1.35, p < 0.001). Similar linearity was present in all examined subgroups, except in patients with CKD in whom a U-shaped association was present and in whom a UACR of 10 to 19 was associated with the best outcomes. Conclusions: The association of UACR with mortality and with progressive CKD is modified in patients with CKD, who experience higher mortality and worse progression of CKD with the lowest levels of UACR. Proteinuria-lowering interventions in patients with advanced CKD should be implemented cautiously, considering the potential for adverse outcomes. © 2013 American College of Cardiology Foundation.

Gerstein H.C.,Hamilton Health Sciences | Miller M.E.,Wake forest University | Genuth S.,Case Western Reserve University | Ismail-Beigi F.,Case Western Reserve University | And 10 more authors.
New England Journal of Medicine | Year: 2011

BACKGROUND: Intensive glucose lowering has previously been shown to increase mortality among persons with advanced type 2 diabetes and a high risk of cardiovascular disease. This report describes the 5-year outcomes of a mean of 3.7 years of intensive glucose lowering on mortality and key cardiovascular events. METHODS: We randomly assigned participants with type 2 diabetes and cardiovascular disease or additional cardiovascular risk factors to receive intensive therapy (targeting a glycated hemoglobin level below 6.0%) or standard therapy (targeting a level of 7 to 7.9%). After termination of the intensive therapy, due to higher mortality in the intensive-therapy group, the target glycated hemoglobin level was 7 to 7.9% for all participants, who were followed until the planned end of the trial. RESULTS: Before the intensive therapy was terminated, the intensive-therapy group did not differ significantly from the standard-therapy group in the rate of the primary outcome (a composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) (P = 0.13) but had more deaths from any cause (primarily cardiovascular) (hazard ratio, 1.21; 95% confidence interval [CI], 1.02 to 1.44) and fewer nonfatal myocardial infarctions (hazard ratio, 0.79; 95% CI, 0.66 to 0.95). These trends persisted during the entire follow-up period (hazard ratio for death, 1.19; 95% CI, 1.03 to 1.38; and hazard ratio for nonfatal myocardial infarction, 0.82; 95% CI, 0.70 to 0.96). After the intensive intervention was terminated, the median glycated hemoglobin level in the intensive-therapy group rose from 6.4% to 7.2%, and the use of glucose-lowering medications and rates of severe hypoglycemia and other adverse events were similar in the two groups. CONCLUSIONS: As compared with standard therapy, the use of intensive therapy for 3.7 years to target a glycated hemoglobin level below 6% reduced 5-year nonfatal myocardial infarctions but increased 5-year mortality. Such a strategy cannot be recommended for high-risk patients with advanced type 2 diabetes. (Funded by the National Heart, Lung and Blood Institute; ClinicalTrials.gov number, NCT00000620.) Copyright © 2011 Massachusetts Medical Society.

Kovesdy C.P.,Memphis Veterans Affairs Medical Center | Bleyer A.J.,Medical Center Boulevard | Molnar M.Z.,Semmelweis University | Ma J.Z.,University of Virginia | And 4 more authors.
Annals of Internal Medicine | Year: 2013

Background: The ideal blood pressure (BP) to decrease mortality rates in patients with non-dialysis-dependent chronic kidney disease (CKD) is unclear. Objective: To assess the association of BP (defined as the combination of systolic BP [SBP] and diastolic BP [DBP] at the individual level) with death in patients with CKD. Design: Historical cohort between 2005 and 2012. Setting: All U.S. Department of Veterans Affairs health care facilities. Patients: 651 749 U.S. veterans with CKD. Measurements: All possible combinations of SBP and DBP were examined in 96 categories from lowest (80/40 mm Hg) to highest (>120/>120 mm Hg), in 10-mm Hg increments. Associations with all-cause mortality were examined in time-dependent Cox models with adjustment for relevant confounders. Results: Patients with SBP of 130 to 159 mm Hg combined with DBP of 70 to 89 mm Hg had the lowest adjusted mortality rates and those in whom both SBP and DBP were concomitantly very high or very low had the highest mortality rates. Patients with moderately elevated SBP combined with DBP no less than 70 mm Hg had consistently lower mortality rates than did patients with ideal SBP combined with DBP less than 70 mm Hg. Results were consistent in subgroups of patients with normal and elevated urinary microalbumin-creatinine ratios. Limitation: Mostly male patients, inability to establish causality, and large number of patients missing proteinuria measurement. Conclusion: The optimal BP in patients with CKD seems to be 130 to 159/70 to 89 mm Hg. It may not be advantageous to achieve ideal SBP at the expense of lower-than-ideal DBP in adults with CKD. © 2013 American College of Physicians.

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