The effect of rate of decline of kidney function on risk for death is not well understood. Using the Department of Veterans Affairs national databases, we retrospectively studied a cohort of 4171 patients who had rheumatoid arthritis and early stage 3 chronic kidney disease (CKD; estimated GFR 45 to 60 ml/min) and followed them longitudinally to characterize predictors of disease progression and the effect of rate of kidney function decline on mortality. After a median of 2.6 years, 1604 (38%) maintained stable kidney function; 426 (10%), 1147 (28%), and 994 (24%) experienced mild, moderate, and severe progression of CKD, respectively (defined as estimated GFR decline of 0 to 1, 1 to 4, and Ͼ4 ml/min per yr). Peripheral artery disease predicted moderate progression of CKD progression. Black race, hypertension, diabetes, cardiovascular disease, and peripheral artery disease predicted severe progression of CKD. After a median of 5.7 years, patients with severe progression had a significantly increased risk for mortality (hazard ratio 1.54; 95% confidence interval 1.30 to 1.82) compared with those with mild progression; patients with moderate progression exhibited a similar trend (hazard ratio 1.10; 95% confidence interval 0.98 to 1.30). Our results demonstrate an independent and graded association between the rate of kidney function decline and mortality. Incorporating the rate of decline into the definition of CKD may transform a static definition into a dynamic one that more accurately describes the potential consequences of the disease for an individual.

Objective: The association between air pollution and the prevalence of overweight and obesity is evaluated. Methods: The population consisted of 30,056 children (aged 2-14 years), randomly selected from 25 districts in Northeast China. Child weight and height were measured, and exposures to particulate matter with an aerodynamic diameter 10 lm (PM 10 ), sulfur dioxide (SO 2 ), nitrogen dioxides (NO 2 ), and Ozone (O 3 ) were estimated from the data collected at monitoring stations in the 25 districts. Using two-level logistic models, we examined the association between the exposure and the prevalence of overweight and obesity. Results: Among the study children, 12.3% (3,704) were overweight and 14.1% (4,233) were obese. After adjusting for confounding factors, an increased prevalence of obesity was associated with an interquartile range increase in PM 10 (31 lg/m 3 ; odds ratio [ORs] ¼ 1.19; 95% confidence interval [CI]: 1.11-1.26), SO 2 (7.4 ppb; ORs ¼ 1.11; 95% CI: 1.03-1.20), NO 2 (5.3 ppb; ORs ¼ 1.13; 95% CI: 1.04-1.22), and O 3 (11.5 ppb; ORs ¼ 1.14; 95% CI: 1.04-1.24). Prevalence of overweight increased with an interquartile range increase in O 3 (11.5 ppb; ORs ¼ 1.09; 95% CI: 1.03-1.15). Conclusions: This study suggests that air pollution is positively associated with an increased likelihood of obesity or overweight in children.

Breastfeeding is associated with smaller associations between air pollution and respiratory conditions in children, suggesting that breastfeeding reduces susceptibility to the respiratory effects of pollutants.

To the editor, Adverse events (AEs) are frequent occurrences in health care systems that not only threaten patients' safety but also cause huge economic losses. Thus, if they were prevented or reduced, it would save numerous lives as well as costs. In China, AEs are also an emerging issue that influences health care quality. To improve AE reporting, professionals' attitudes about AE reporting and views regarding factors that discourage AE reporting should be known; these may be different from those in other foreign countries. Doctors and nurses-with different levels of education, working experience, and health care provision responsibilities-may have different attitudes toward AE reporting 1 and different views about the factors that inhibit reporting. Little research has examined these differences between doctors and nurses. Therefore, we conducted research to determine the differences between doctors' and nurses' attitudes toward AE reporting and assessments of factors that inhibit reporting.A cross-sectional survey using anonymous questionnaires was administered between March and December 2011. Respondents included 326 doctors and 467 nurses from 13 hospitals in Jiangsu, Hubei, and Zhejiang provinces in China. All the respondents joined the study voluntarily and provided informed consent.The questionnaire assessed 3 areas of daily medical practice: (1) socioeconomic characteristics, (2) awareness and use of AE reporting, and (3) factors that discourage doctors and nurses from reporting AEs. Following review by a panel of professionals to assess content validity, the questionnaire was piloted with 24 doctors and 30 nurses. Test-retest reliability was determined using a κ-statistic, and only questions for which there was at least moderate reproducibility (κ > 0.4) were used.The results showed that most doctors and nurses (80.1%) were aware of the AE reporting in their hospitals. Nurses were more aware of AE reporting than doctors (88.0% vs 71.7%; relative risk = 1.23; P < .001). For doctors, the major inhibiting factors to reporting were the fear of having their bonuses reduced, the belief that it is not their responsibility to report others' mistakes, and the fear of consequences for their future career (Table 1). For nurses, the major inhibiting factors were the belief that it is not their responsibility to report others' mistakes, the fear that their bonuses would be reduced, and the fear of acquiring a negative reputation (Table 1). Doctors and nurses differed in their opinions about whether reporting AEs had consequences for their future career (P = .001), whether they recognized that an AE had occurred (P < .05), whether there was a supportive environment for reporting AEs in the department (P < .001), and whether the feedback from AE reporting was lacking (P < .001), among other factors (Table 1).In China and other countries with underdeveloped AE reporting systems, the person who caused the AE is unfairly punished. Therefore, the culture of blame makes medical health care professionals reluctant to repor...

Objective: The effects of adverse childhood experiences (ACE) on children and adolescents’ health status such as obesity are understudied. The current study addressed the effect of ACE on obesity status during childhood utilising multiple waves of national panel data. Design: Longitudinal survey. Setting: Data were drawn from three waves of the second cohort of the National Survey of Child and Adolescent Well-Being (NSCAW II). NSCAW II study sampled cases from Child Protective Services investigations that were closed between February 2008 and April 2009 nationwide. We measured ACE cumulatively and as separate events and stratified by gender. Participants: Totally, 3170 youth births to 14 years of age at baseline. Results: A count measure of ACE is indeed associated with greater odds of obesity during childhood. Differential effects for different types of ACE were also found, most notably neglect. For girls, physical and psychological neglect increased odds of obesity. Conclusions: Findings support evidence for the importance of using both a count measure of ACE as well as separating out single events by gender.