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2.  Extreme Pain From Brown Recluse Spider Bites Model for Cytokine-Driven Pain 
JAMA dermatology  2014;150(11):1205-1208.
Importance
Bites from the brown recluse spider (BRS) can cause extreme pain. We propose cytokine release as a cause of the discomfort and a central mechanism through glial cell upregulation to explain measured pain levels and time course.
Observations
Twenty-three BRS bites were scored at a probable or documented level clinically, and an enzyme-linked immunosorbent assay was used to confirm the presence of BRS venom. The mean (SD) pain level in these cases 24 hours after the spider bite was severe: 6.74 (2.75) on a scale of 0 to 10. Narcotics may be needed to provide relief in some cases. The difference in pain level by anatomic region was not significant. Escalation observed in 22 of 23 cases, increasing from low/none to extreme within 24 hours, is consistent with a cytokine pain pattern, in which pain increases concomitantly with a temporal increase of inflammatory cytokines.
Conclusions and Relevance
These findings in BRS bites support the hypothesis of cytokine release in inflammatory pain. A larger series is needed to confirm the findings reported here. The extreme pain from many BRS bites motivates us to find better prevention and treatment techniques.
doi:10.1001/jamadermatol.2014.605
PMCID: PMC4229416  PMID: 25076008
3.  Electronic health record functionality needed to better support primary care 
Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This article presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and meaningful use (MU) objectives to define EHR functionality. Current objectives remain focused on disease rather than the whole person, ignoring factors such as personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time, as well as patient-partnering activities, support for team-based care, population-management tools that deliver care, and reduced documentation burden. While stage 3 MU's focus on outcomes is laudable, enhanced functionality is still needed, including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies.
doi:10.1136/amiajnl-2013-002229
PMCID: PMC4147605  PMID: 24431335
Primary Care; Electronic Health Records; Meaningful Use
4.  Selective Serotonin Reuptake Inhibitors and Night Sweats in a Primary Care Population 
Drugs - Real World Outcomes  2015;2(1):29-33.
Objective
Several small published case reports have suggested that selective serotonin reuptake inhibitors (SSRIs) can cause night sweats. The purpose of this study was to investigate this possibility further and to explore possible associations between night sweats and other commonly prescribed medications.
Design
Cross-sectional, secondary data analysis.
Setting
Data were obtained during the Oklahoma Longitudinal Assessment of the Health Outcomes of Mature Adults, a longitudinal cohort study carried out in the Oklahoma Physicians Resource/Research Network.
Participants
413 adult primary care patients aged 65–94 years.
Interventions
Current regular use of one of 35 classes of medication.
Main Outcome Measures
At least moderate night sweats during the prior month.
Results
A total of 38 (9.2 %) reported night sweats. Age, gender, body mass index, and total number of medications taken regularly were not associated with night sweats. After adjusting for age and gender, SSRIs (odds ratio [OR] 3.01; 95 % confidence interval [CI] 1.26–7.19), angiotensin receptor blockers (ARBs) (OR 3.44; 95 % CI 1.36–8.69), and thyroid hormone supplements (OR 2.53; 95 % CI 1.24–5.15) were the only classes of medications associated with night sweats.
Conclusions
Use of SSRIs may well be associated with night sweats in older patients. Associations found between night sweats and ARBs and thyroid supplements warrant further study.
doi:10.1007/s40801-015-0007-8
PMCID: PMC4883206  PMID: 27747615
5.  Leveraging practice-based research networks to accelerate implementation and diffusion of chronic kidney disease guidelines in primary care practices: a prospective cohort study 
Background
Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices.
Methods
Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians. They received only monthly practice facilitation. The primary outcomes were adherence to primary care-relevant process-of-care recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Performance was determined retrospectively by medical records abstraction. Practice priority, change capacity, and care process content were measured before and after the interventions.
Results
Following the intervention, wave I practices increased the use of ACEIs/ARBs, discontinuation of NSAIDs, testing for anemia, and testing and/or treatment for vitamin D deficiency. Most were able to recruit two additional practices for wave II, and wave II practices also increased their use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency.
Conclusions
With some assistance, early adopter practices can facilitate the diffusion of evidence-based approaches to other practices. PBRNs are well-positioned to replicate this process for other evidence-based innovations.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0169-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-014-0169-x
PMCID: PMC4245828  PMID: 25416998
Implementation; Diffusion; Primary care; Practice-based research network; Chronic kidney disease
6.  Cognitive and daily functioning in older adults with vegetative symptoms of depression 
Objectives
In primary care 50–95% of patients with depression present with vegetative symptoms (VS). Based on the extant literature, older adults showing VS (but no dysphoria) may show functional impairment but this hypothesis has not been empirically tested. The goal of this study was to examine neurocognitive and daily functioning of elderly patients showing exclusively VS in comparison with patients presenting with VS and dysphoria.
Methods
Seven hundred and eighty-seven primary care patients received measures of neurocognition and daily functioning. Neurocognition was measured with the repeatable battery for the assessment of neuropsychological status (RBANS). Three groups were compared: (1) patients with two or more VS of depression without dysphoria (VS − D), (2) patients with at least one VS and dysphoria (VS + D), and (3) comparison patients without multiple VS or dysphoria.
Results
Nearly one third of the sample (31%) fell into the VS − D group, whereas 15% fell into the VS + D group. Both VS groups showed poorer neurocognition and activities of daily living than comparisons. Only one subtest of the RBANS (i.e., picture naming) showed a significant difference between VS + D and VS − D, and there was no significant difference on daily functioning. VS − D patients reported less frequent past history of depression and endorsed less anxiety compared to VS + D.
Conclusions
Elderly patients presenting with clusters of VS with or without dysphoria show poorer neurocognitive and functional performance. Relative poorer cognition and daily functioning in VS − D are potential harbingers of further decline and consistent with under-reporting of sadness in older age.
doi:10.1002/gps.2376
PMCID: PMC3789530  PMID: 19806600
vegetative symptoms; primary care; late-life depression; nondysphoric depression; neurocognition; right hemisphere functions; subthreshold depression
7.  Brief Report: The Temporal Stability of the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index in Geriatric Samples 
The Effort Index (EI) of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was developed to identify inadequate effort. Although researchers have examined its validity, the reliability of the EI has not been evaluated. The current study examined the temporal stability of the EI across 1 year in two independent samples of older adults. One sample consisted of 445 cognitively intact older adults (mean age = 72.89; 59% having 12–15 years of education) and the second sample consisted of 51 individuals diagnosed with amnestic Mild Cognitive Impairment (mean age = 82.41; 41% having 12–15 years of education). For both samples, the EI was found to have low stability (Spearman's ρ = .32–.36). When participants were divided into those whose EI stayed stable or improved versus those whose EI worsened (i.e., declining effort) on retesting, it was observed that individuals with lower baseline RBANS Total scores tended to worsen on the EI across time. Overall, the findings suggest low temporal stability of the EI in two geriatric samples. In particular, individuals with poorer cognition at baseline could present with poorer effort across time. These findings also suggest the need to further examine the temporal stability of other effort measures.
doi:10.1093/arclin/acr072
PMCID: PMC3286195  PMID: 22075575
Malingering/symptom validity testing; Elderly/geriatrics/aging; Mild cognitive impairment
8.  Interpreting the psychometric properties of the components of primary care instrument in an elderly population 
Objective:
To determine the psychometric properties of the Components of Primary Care Instrument (CPCI) in a patient population aged 65 or older.
Materials and Methods:
795 participants in the OKLAHOMA Studies, a longitudinal population-based study of predominantly Caucasian, elderly patients, completed the CPCI. Reliability analysis and confirmatory factor analysis were done to provide psychometric properties for this elderly sample. Models were constructed and tested to determine the best fit for the data including the addition of a method factor for negatively worded items.
Results:
Cronbach's alphas were comparable to values reported in prior studies. The confirmatory factor analysis with factor inter-correlations and a method factor each improved the fit of the factor model to the data. The combined model's fit approached the level conventionally recognized as adequate.
Conclusion:
CPCI appears to be a reliable tool for describing patient perceptions of the quality of primary care for patients over age 65.
doi:10.4103/2230-8229.98299
PMCID: PMC3410175  PMID: 22870416
Components of primary care instrument; elderly; older patients; primary care; reliability; validity
9.  The RBANS Effort Index: Base rates in geriatric samples 
Applied neuropsychology  2011;18(1):11-17.
The Effort Index (EI) of the RBANS was developed to assist clinicians in discriminating patients who demonstrate good effort from those with poor effort. However, there are concerns that older adults might be unfairly penalized by this index, which uses uncorrected raw scores. Using five independent samples of geriatric patients with a broad range of cognitive functioning (e.g., cognitively intact, nursing home residents, probable Alzheimer’s disease), base rates of failure on the EI were calculated. In cognitively intact and mildly impaired samples, few older individuals were classified as demonstrating poor effort (e.g., 3% in cognitively intact). However, in the more severely impaired geriatric patients, over one third had EI scores that fell above suggested cut-off scores (e.g., 37% in nursing home residents, 33% in probable Alzheimer’s disease). In the cognitively intact sample, older and less educated patients were more likely to have scores suggestive of poor effort. Education effects were observed in 3 of the 4 clinical samples. Overall cognitive functioning was significantly correlated with EI scores, with poorer cognition being associated with greater suspicion of low effort. The current results suggest that age, education, and level of cognitive functioning should be taken into consideration when interpreting EI results and that significant caution is warranted when examining EI scores in elders suspected of having dementia.
doi:10.1080/09084282.2010.523354
PMCID: PMC3074382  PMID: 21390895
symptom validity testing; RBANS; geriatric assessment
10.  Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making 
BMC Nephrology  2011;12:47.
Background
Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.
Methods
We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.
Results
More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).
Conclusions
In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.
doi:10.1186/1471-2369-12-47
PMCID: PMC3192737  PMID: 21943241
11.  Utility of the RBANS in detecting cognitive impairment associated with Alzheimer’s disease: Sensitivity, specificity, and positive and negative predictive powers 
Although initially developed as a brief dementia battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has not yet demonstrated its sensitivity, specificity, and positive and negative predictive powers in detecting cognitive impairment in patients with Alzheimer’s disease (AD). Therefore, the current study examined the clinical utility of the RBANS by comparing two age-, education-, and gender-matched groups: patients with AD (n=69) and comparators (n=69). Significant differences (p<0.001) were observed on the RBANS Total score, all five Indexes, and all twelve subtests, with patients performing worse than the comparison participants. An optimal balance between sensitivity and specificity on RBANS scores was obtained when cutoffs of one and one and a half standard deviations below the mean of the comparison sample were implemented. Areas under the Receiver Operating Characteristic curves for all RBANS Indexes were impressive though Immediate and Delayed Memory Indexes were excellent (0.96 and 0.98, respectively). Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.
doi:10.1016/j.acn.2008.06.004
PMCID: PMC2570647  PMID: 18639437
Alzheimer’s disease; dementia; diagnostic accuracy; Repeatable Battery for the Assessment of Neuropsychological Status
12.  Utility of the RBANS in detecting cognitive impairment associated with Alzheimer's disease: Sensitivity, specificity, and positive and negative predictive powers 
Abstract
Although initially developed as a brief dementia battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has not yet demonstrated its sensitivity, specificity, and positive and negative predictive powers in detecting cognitive impairment in patients with Alzheimer's disease (AD). Therefore, the current study examined the clinical utility of the RBANS by comparing two age-, education-, and gender-matched groups: patients with AD (n=69) and comparators (n=69). Significant differences (p<0.001) were observed on the RBANS Total score, all 5 Indexes, and all 12 subtests, with patients performing worse than the comparison participants. An optimal balance between sensitivity and specificity on RBANS scores was obtained when cutoffs of one and one and a half standard deviations below the mean of the comparison sample were implemented. Areas under the Receiver Operating Characteristic curves for all RBANS Indexes were impressive though Immediate and Delayed Memory Indexes were excellent (0.96 and 0.98, respectively). Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.
doi:10.1016/j.acn.2008.06.004
PMCID: PMC2570647  PMID: 18639437
Alzheimer's disease; Dementia; Diagnostic accuracy; Repeatable Battery for the Assessment of Neuropsychological Status

Results 1-12 (12)