Papers by Rebecca Speckman
Seminars in Dialysis, Jun 28, 2008
Central venous catheter (CVC) use at hemodialysis (HD) initiation remains high, despite reports o... more Central venous catheter (CVC) use at hemodialysis (HD) initiation remains high, despite reports of CVC-associated morbidity and mortality, and efforts at early arteriovenous fistula placement. In order to determine predictors of CVC use at the start of HD, data from the end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project was linked to the Centers for Medicare & Medicaid Services Medical Evidence (2728) Form. Of the 4071 incident hemodialysis patients in study years 1999-2003, 71.6% used a CVC at dialysis initiation. After controlling for demographic and co-morbid variables, patients with a CVC were 24% more likely to be female (p = 0.006), and 38% more likely to have ischemic heart disease (p = 0.002), while those with obesity (BMI ≥30) were 24% less likely to start dialysis with a CVC (p = 0.006). Pre-ESRD hypoalbuminemia (< 3.5 g/dl) was associated with a twofold higher risk of CVC use (p = <0.001), while patients with pre-ESRD anemia (hgb < 11 g/dl) were 29% more likely to use a CVC at dialysis initiation (p = 0.006) compared to those with hemoglobin ≥11 g/dl. Patients receiving predialysis erythropoietin had a 41% lower odds of CVC use at dialysis initiation (p = <0.001). Finally, dialysis year was predictive of CVC use; in 2002, 76% of patients initiated dialysis with a CVC compared with 66% in 1998 (p < 0.001). Overall, female gender, ischemic heart disease, lack of obesity, factors suggesting poor pre-ESRD care, and successive year of dialysis initiation were predictive of CVC use at hemodialysis initiation. The type of hemodialysis access in place at the initiation of hemodialysis among end-stage renal disease (ESRD) patients carries variable risk of infection and mortality. Studies have demonstrated that a central venous catheter (CVC) is associated with increased risk of infection-related and all-cause mortality compared to either the arteriovenous fistula (AVF) or prosthetic graft (1-4). In addition, compared with patients who receive an AVF, patients with a CVC experience poorer clearance of blood toxins secondary to unreliable blood flow, higher rates of bloodstream infections, anemia, central vein scarring with subsequent vein occlusion, and antibiotic resistance (5-10). Despite these disadvantages, the majority of ESRD patients in the United States initiate dialysis with a CVC. CVC use at dialysis initiation among incident hemodialysis patients ranges from 56.8% to 66% in the United States (2,11). It is unclear why high rates of CVC use persist among
American Journal of Kidney Diseases, Feb 1, 2007
Background-Early arteriovenous fistula (AVF) creation is necessary to curb the use of central ven... more Background-Early arteriovenous fistula (AVF) creation is necessary to curb the use of central venous catheters (CVCs) and reduce their complications. We sought to examine patient characteristics that may influence persistent CVC use 90 days after dialysis therapy initiation among patients using a CVC. Methods-Data from the 1999 to 2003 Clinical Performance Measures Project was linked to the Centers for Medicare & Medicaid Services Medical Evidence (2728) form. Results-Most patients (59.4%) starting dialysis with a CVC failed to transition to permanent access within 90 days, whereas 25.4% received a graft and only 15.2% received an AVF. Older patients (>75 years) were more than 2-fold more likely to remain CVC dependent at 90 days (P = 0.0.001) compared with those younger than 50 years. In addition, race and sex were highly predictive of CVC dependence at 90 days; black females, white females, and black males were 75% (P < 0.001), 61% (P < 0.001), and 35% (P = 0.023) more likely than white males to maintain CVC use, whereas patients with ischemic heart disease and peripheral vascular disease were 35% (P = 0.023) and 39% (P = 0.007) more likely to remain CVC dependent at 90 days, respectively. Conclusion-Prolonged CVC dependence is more likely to occur among patients of older age, females, blacks, and those with cardiovascular comorbidity, suggesting inadequate or late access referral or greater primary access failure. Our findings suggest possible missed opportunities for early conversion of patients to permanent vascular access that may vary by race and sex. INDEX WORDS Hemodialysis vascular access Placement and maintenance of an effective hemodialysis vascular access is essential for safe and adequate hemodialysis therapy, and access-related complications remain one of the most important sources of morbidity and cost among persons with end-stage renal disease (ESRD), with total annual costs exceeding $1 billion annually. 1-3 The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Vascular Access recommend early placement and use of an autogenous arterio-venous fistula (AVF) among at least 50% of incident hemodialysis patients. 4 The AVF has longer patency and fewer infectious
PM&R, 2019
This article has been accepted for publication and undergone full peer review but has not been th... more This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as
Seminars in Dialysis, 2008
Central venous catheter (CVC) use at hemodialysis (HD) initiation remains high, despite reports o... more Central venous catheter (CVC) use at hemodialysis (HD) initiation remains high, despite reports of CVC‐associated morbidity and mortality, and efforts at early arteriovenous fistula placement. In order to determine predictors of CVC use at the start of HD, data from the end‐stage renal disease (ESRD) Clinical Performance Measures (CPM) Project was linked to the Centers for Medicare & Medicaid Services Medical Evidence (2728) Form. Of the 4071 incident hemodialysis patients in study years 1999–2003, 71.6% used a CVC at dialysis initiation. After controlling for demographic and co‐morbid variables, patients with a CVC were 24% more likely to be female (p = 0.006), and 38% more likely to have ischemic heart disease (p = 0.002), while those with obesity (BMI ≥30) were 24% less likely to start dialysis with a CVC (p = 0.006). Pre‐ESRD hypoalbuminemia (<3.5 g/dl) was associated with a twofold higher risk of CVC use (p = <0.001), while patients with pre‐ESRD anemia (hgb <11 g/dl) ...
Seminars in Dialysis, 2008
The arteriovenous fistula (AVF) is the recommended form of dialysis vascular access, however, lim... more The arteriovenous fistula (AVF) is the recommended form of dialysis vascular access, however, limited studies suggest that AVF creation may result in increased cardiovascular stress and remodeling. To explore the contribution of vascular access type to cardiovascular‐related (CV) mortality, we analyzed USRDS Clinical Performance Measures data comprising 4854 patients that initiated dialysis between October 1, 1999–December 31, 2004. CV mortality included death from acute myocardial infarction, atherosclerotic heart disease, cardiomyopathy, arrhythmia, cardiac arrest or stroke. Risk of cardiovascular mortality during a 4‐year observation was analyzed by Cox‐regression methods with adjustments for demographic and co‐morbid conditions. AVF use was strongly associated with lower all‐cause and CV mortality. After adjustment for covariates, AVF use 90 days after dialysis initiation remained significantly associated with lower cardiovascular mortality [hazard ratio (HR) 0.69, p = 0.0004] c...
Journal of the American Society of Nephrology, 2007
This report describes the prevalence and characteristics of people with a family history of ESRD ... more This report describes the prevalence and characteristics of people with a family history of ESRD in a first-degree relative (FH-ESRD). This is a cross-sectional study of individuals in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, a population-based sample of US residents who are 45 yr and older. FH-ESRD was ascertained at baseline among 12,030 participants of the cohort, and multivariate logistic regression was used to identify characteristics that were independently associated with FH-ESRD. FH-ESRD was reported by 9.5% of participants. Individual characteristics that were independently associated with FH-ESRD included black race (odds ratio [OR] 2.14; 95% confidence interval [CI] 1.82 to 2.53); female gender (OR 1.28; 95% CI 1.08 to 1.51); a history of diabetes (OR 1.22; 95% CI 1.02 to 1.47); a 1-SD change in the log of the C-reactive protein level (OR 1.10; 95% CI 1.01 to 1.19); and World Health Organization body mass index weight categories normal (OR 2.11; 95% CI 0.66 to 6.79), overweight (OR 2.64; 95% CI 0.82 to 8.42), and obese (OR 3.48; 95% CI 1.09 to 11.1) compared with underweight. Black but not white individuals with FH-ESRD were more likely to have an estimated GFR <60 ml/min per 1.73 m 2. There is a high prevalence of FH-ESRD among US adults, and the prevalence of FH-ESRD was higher among lack individuals. Individuals with a positive family history were more likely to have diabetes and to be obese. If confirmed, then these findings suggest that individuals with FH-ESRD may benefit from interventions to improve the detection and treatment of chronic kidney disease risk factors such as diabetes and obesity.
JAMA, 2008
Context Former child soldiers are considered in need of special mental health interventions. Howe... more Context Former child soldiers are considered in need of special mental health interventions. However, there is a lack of studies investigating the mental health of child soldiers compared with civilian children in armed conflicts. Objective To compare the mental health status of former child soldiers with that of children who have never been conscripts of armed groups. Design, Setting, and Participants Cross-sectional cohort study conducted in March and April 2007 in Nepal comparing the mental health of 141 former child soldiers and 141 never-conscripted children matched on age, sex, education, and ethnicity. Main Outcome Measures Depression symptoms were assessed via the Depression Self Rating Scale, anxiety symptoms via the Screen for Child Anxiety Related Emotional Disorders, symptoms of posttraumatic stress disorder (PTSD) via the Child PTSD Symptom Scale, general psychological difficulties via the Strength and Difficulties Questionnaire, daily functioning via the Function Impairment tool, and exposure to traumatic events via the PTSD Traumatic Event Checklist of the Kiddie Schedule of Affective Disorders and Schizophrenia. Results Participants were a mean of 15.75 years old at the time of this study, and former child soldiers ranged in age from 5 to 16 years at the time of conscription. All participants experienced at least 1 type of trauma. The numbers of former child soldiers meeting symptom cutoff scores were 75 (53.2%) for depression, 65 (46.1%) for anxiety, 78 (55.3%) for PTSD, 55 (39.0%) for psychological difficulties, and 88 (62.4%) for function impairment. After adjusting for traumatic exposures and other covariates, former soldier status was significantly associated with depression (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.31-4.44) and PTSD among girls (OR, 6.80; 95% CI, 2.16-21.58), and PTSD among boys (OR, 3.81; 95% CI, 1.06-13.73) but was not associated with general psychological difficulties (OR, 2.08; 95% CI, 0.86-5.02), anxiety (OR, 1.63; 95% CI, 0.77-3.45), or function impairment (OR, 1.34; 95% CI, 0.84-2.14). Conclusion In Nepal, former child soldiers display greater severity of mental health problems compared with children never conscripted by armed groups, and this difference remains for depression and PTSD (the latter especially among girls) even after controlling for trauma exposure.
Diabetes Care, 2004
OBJECTIVE—End-stage renal disease (ESRD) patients, especially those with diabetes, have an increa... more OBJECTIVE—End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients. RESEARCH DESIGN AND METHODS—The study population consisted of incident hemodialysis patients from the study years 1996–1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA. RESULTS—Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4–12.0), cardiovascular comorbidity (1.8, 1.2–2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1–3.3), and lower serum albumin l...
Annals of Human Biology, 2009
Background-The causes of ethnic and caste-based disparities in mental health are poorly understoo... more Background-The causes of ethnic and caste-based disparities in mental health are poorly understood. Aim-To identify mediators underlying caste-based disparities in mental health in Nepal. Subjects and methods-A mixed methods ethnographic and epidemiological study of 307 adults (Dalit/Nepali, n=75; high caste Brahman and Chhetri, n=232) assessed with Nepali versions of Beck Depression (BDI) and Anxiety (BAI) Inventories. Results-One third (33.7%) of participants were classified as depressed: Dalit/Nepali 50.0%, high caste 28.4%. One quarter (27.7%) of participants were classified as anxious: Dalit/Nepali 50.7%, high caste 20.3%. Ethnographic research identified four potential mediators: stressful life events, owning few livestock, no household income, and lack of social support. The direct effect of caste was 1.08 (95% CI-1.10-3.27) on depression score and 4.76 (95% CI 2.33-7.19) on anxiety score. All four variables had significant indirect (mediation) effects on anxiety, and all but social support had significant indirect effects on depression. Conclusion-Caste-based disparities in mental health in rural Nepal are statistically mediated by poverty, lack of social support, and stressful life events. Interventions should target these areas to alleviate the excess mental health burden born by Dalit/Nepali women and men.
American Journal of Kidney Diseases, 2006
Background: Obesity is an established risk factor for chronic kidney disease and aggregates in fa... more Background: Obesity is an established risk factor for chronic kidney disease and aggregates in families. The objective of this study is to examine the relationship between obesity and family history of end-stage renal disease (ESRD). Methods: Data were collected from 25,883 incident patients with ESRD in US ESRD Network 6 (Georgia, North Carolina, and South Carolina) dialysis clinics between 1995 and 2003. Family history is defined as a first-or second-degree relative with ESRD. Body mass index (BMI) at dialysis therapy initiation was classified as underweight (BMI < 18.5 kg/m 2), normal (BMI, 18.5 to <25 kg/m 2), overweight (BMI, 25 to < 30 kg/m 2), obese (BMI, 30 to <35 kg/m 2), or morbidly obese (BMI > 35 kg/m 2). Results: Twenty-three percent of patients reported a family history of ESRD. Of patients reporting a family history of ESRD, 5.5% were underweight, 32.5% had normal BMI, 28.0% were overweight, 17.3% were obese, and 16.7% were morbidly obese. After controlling for age, race, sex, primary cause of ESRD, history of diabetes, history of hypertension, and estimated glomerular filtration rate at dialysis therapy initiation, reported family history of ESRD was associated with being overweight (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.08 to 1.26), obese (OR, 1.25; 95% CI, 1.14 to 1.37), and morbidly obese (OR, 1.40; 95% CI, 1.27 to 1.55). Conclusion: Obesity at dialysis therapy initiation was associated independently with reported family history of ESRD. This finding suggests that behavioral factors, adiposity-related genes, and gene-by-BMI interaction may contribute to familial risk for ESRD. This finding also suggests that management of obesity may be even more important for patients with a family history of ESRD than for the general population.
American Journal of Kidney Diseases, 2007
Background-Early arteriovenous fistula (AVF) creation is necessary to curb the use of central ven... more Background-Early arteriovenous fistula (AVF) creation is necessary to curb the use of central venous catheters (CVCs) and reduce their complications. We sought to examine patient characteristics that may influence persistent CVC use 90 days after dialysis therapy initiation among patients using a CVC. Methods-Data from the 1999 to 2003 Clinical Performance Measures Project was linked to the Centers for Medicare & Medicaid Services Medical Evidence (2728) form. Results-Most patients (59.4%) starting dialysis with a CVC failed to transition to permanent access within 90 days, whereas 25.4% received a graft and only 15.2% received an AVF. Older patients (>75 years) were more than 2-fold more likely to remain CVC dependent at 90 days (P = 0.0.001) compared with those younger than 50 years. In addition, race and sex were highly predictive of CVC dependence at 90 days; black females, white females, and black males were 75% (P < 0.001), 61% (P < 0.001), and 35% (P = 0.023) more likely than white males to maintain CVC use, whereas patients with ischemic heart disease and peripheral vascular disease were 35% (P = 0.023) and 39% (P = 0.007) more likely to remain CVC dependent at 90 days, respectively. Conclusion-Prolonged CVC dependence is more likely to occur among patients of older age, females, blacks, and those with cardiovascular comorbidity, suggesting inadequate or late access referral or greater primary access failure. Our findings suggest possible missed opportunities for early conversion of patients to permanent vascular access that may vary by race and sex. INDEX WORDS Hemodialysis vascular access Placement and maintenance of an effective hemodialysis vascular access is essential for safe and adequate hemodialysis therapy, and access-related complications remain one of the most important sources of morbidity and cost among persons with end-stage renal disease (ESRD), with total annual costs exceeding $1 billion annually. 1-3 The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Vascular Access recommend early placement and use of an autogenous arterio-venous fistula (AVF) among at least 50% of incident hemodialysis patients. 4 The AVF has longer patency and fewer infectious
Pm&r, Aug 1, 2019
For rehabilitation clinicians to independently interpret the literature, they must understand evi... more For rehabilitation clinicians to independently interpret the literature, they must understand evidence-based practice strategies for answering and interpreting clinical research questions. Summary measures, sometimes called measures of frequency or measures of occurrence, summarize the occurrence of outcomes within a group of people. Measures of effect, sometimes called measures of association, quantify the comparison of the outcomes between two groups and are used to inform interpretation of clinical significance. This feature introduces these concepts, building on concepts presented in previous Methodology Matters features. The mission of the Methodology Matters series is to educate rehabilitation clinicians, researchers, and peer reviewers in the principles and application of evidence-based practice using rehabilitation examples. We do not expect all rehabilitation clinicians to do research, but to have the vocabulary and knowledge base to understand and interpret rehabilitation research.
Stress Fractures in Athletes, 2014
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Papers by Rebecca Speckman