IntroductionCurrent estimates indicate that up to 50–75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders.MethodsThree hundred patients aged 65–89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes.ResultsWhen SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues.DiscussionSAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports.

Background: Antimicrobial peptides (AMPs) are key effectors of urinary tract innate immunity. Identifying differences in urinary AMP levels between younger and older adults is important in understanding older adults' susceptibility and response to urinary tract infections (UTI) and AMP use as diagnostic biomarkers. We hypothesized that uninfected older adults have higher urinary human neutrophil peptides 1-3 (HNP 1-3), human alpha-defensin-5 (HD-5), and human beta-defensin-2 (hBD-2), but lower urinary cathelicidin (LL-37) than younger adults.Methods: We conducted a cross-sectional study of patients aged >= 18 years completing a family medicine clinic nonacute visit. Enzyme-linked immunosorbent assays were performed for AMPs. We identified associations between age and AMPs using unadjusted and multivariable linear regression models.Results: Of the 308 subjects, 144 (46.8%) were >= 65 years of age. Comparing age >= 65 versus < 65 years, there were no significant differences in HNP 1-3 (p = .371), HD5 (p = .834), or LL-37 (p = .348) levels. Values for hBD-2 were lower in older adults versus younger (p < .001). In multivariable analyses, older males and females had significantly lower hBD-2 levels (p < .001 and p = .004). Models also showed urine leukocyte esterase was associated with increased levels of HNP 1-3 and HD5; hematuria with increased hBD-2; and urine cultures with contamination with increased HNP 1-3 and hBD-2.Conclusions: Baseline urinary HNP 1-3, HD-5, and LL-37 did not vary with age. Older adults had lower baseline hBD-2. This finding has implications for the potential use of urinary AMPs as diagnostic markers and will facilitate further investigation into the role of innate immunity in UTI susceptibility in older adults.

Background The American Heart Association defines ideal cardiovascular health based on 8 risk factors (Life's Essential 8 [LE8]); a high LE8 score (range 0–100) reflects greater adherence to their recommendations. Weight status influences cardiovascular health, yet individuals may use detrimental diet and weight loss strategies to improve weight status. We assessed differences in LE8 adherence, diet quality, and weight loss strategies between those with and without a recent history of clinically significant weight loss (CSWL). Methods and Results Data from 2007 to 2016 National Health and Nutrition Examination Survey questionnaires, clinical measures, and 24‐hour dietary recalls were assessed to determine LE8 adherence, diet quality (Healthy Eating Index), and weight loss strategies between adults with: (1) intentional CSWL ≥5%; and (2) non‐CSWL <5%, weight maintenance, or weight gain over the past 12 months using ANCOVA and chi‐square tests. Those with CSWL demonstrated higher scores for diet quality (P=0.014), physical activity (P<0.001), and blood lipids (P<0.001). Those without CSWL reported lower BMI (P<0.001). There were no differences in total LE8 cardiovascular health scores between those with and without CSWL. More individuals with CSWL reported weight loss strategies of exercising (P=0.016); those without CSWL reported skipping meals (P=0.002) and using prescription diet pills (P<0.001). Conclusions Greater adherence to the LE8 recommendations was observed among individuals with CSWL, although overall LE8 scores were low. Future research should address the implementation of evidence‐based strategies that improve diet quality while promoting optimal cardiovascular health among those with intent to lose weight.

Background Optimal clinical care, diagnosis and treatment requires accurate blood pressure (BP) values. The primary objective was to compare BP readings taken while adhering to American Heart Association (AHA) guidelines to those typical of routine clinical care. Specifically studied: the combined effect of feet flat on the floor, back supported, and arm supported with cuff at heart level, while adhering to other guideline recommendations. Methods In this prospective, randomised, three-group cohort study, a modified cross-over design was applied in a primary care outpatient office setting in Columbus (OH, USA). Eligible participants were adults (aged >= 18 years) with an arm circumference of >= 18 cm and <= 42 cm who did not have a renal dialysis shunt or a previous or current diagnosis of atrial fibrillation. 150 recruited volunteers meeting the inclusion criteria were randomly randomised into the three groups. Group methodologies were BP readings taken on a fixed-height exam table followed by readings taken in an exam chair with adjustable positioning options (Group A), readings taken in the reverse order, chair then table (Group B), and both sets of readings in the exam chair (Group C). A rest period occurred before each set of readings. Group C was included for the purpose of obtaining an independent estimate of the order effect. The order in which the two types of readings (table vs chair) were taken was randomised. The primary outcome was the difference between the mean of three BP readings taken on the table and the mean of three readings taken in the chair. Findings Between September and October, 2022, 150 participants were enrolled in the study; all 150 of whom completed testing: 48 in Group A, 49 in Group B, 53 in Group C. The mean systolic/diastolic BP (SBP/DBP) of readings taken on the table (Group A first readings, Group B second readings) were 7.0/4.5 mmHg higher than those taken in the chair (Group A second readings, Group B first readings); both statistically significant, p < 0.0001. These findings show that AHA-recommended positioning-feet flat on the floor, back supported, arm supported with the BP cuff at heart level-results in substantially lower BP values than improper positioning. The mean SBP/DBP of the first set of readings taken on the chair were 1.6/0.6 mmHg higher than for the second set of readings (Group C, included to estimate order effect). Interpretation The observed benefit of proper positioning is sufficient to change the BP classification of several million patients from having hypertension to not having hypertension and therefore avoiding medication and/or intense follow-up.

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid’s Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio’s Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

INTRODUCTION:The objective of this study was to determine the preliminary feasibility and acceptability of screening for family functioning in a family medicine setting, and secondarily to explore differences in parent-child dyad interest in behavioral health service utilization by demographics, pediatric behavioral symptoms, and pediatric QOL. METHOD:The McMaster Family Assessment Device General Functioning subscale was used to assess family functioning among 58 parent-child (ages 11-26) dyads in family medicine. Feasibility and acceptability were assessed through study interest and participation and interest and attendance in behavioral health services. Associations with interest in services, Child Behavior Checklist, Pediatric QOL Inventory, and select demographics were conducted using independent samples t-tests and Mann-Whitney tests. RESULTS:Fifty-eight parent-child dyads participated in the study. Close to half of dyads who expressed interest in the survey completed the assessment (46%). Dyads who completed the assessment had a family functioning impairment rate of 45%, and 54% of dyads with impairment expressed interest in services. Interest in services was significantly associated with several domains of childrens' behavioral health symptoms and pediatric QOL, but no demographics. DISCUSSION:Dyads experienced high rates of clinically significant family functioning impairment, without interest in receiving colocated behavioral health services. Future research should continue to explore how family functioning assessment can be utilized to identify child behavioral health symptoms broadly and engage families in colocated behavioral health services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Purpose: Children and young adults underutilize behavioral health services, in part due to the challenges with identifying and providing services for child behavioral health in primary care. The objective of this study was to determine if a brief assessment of family functioning captures specific child psychosocial symptoms in a Family Medicine practice. Design and methods: Eighty-three parent child dyads, in which the parent or child was a patient at the Family Medicine practice, participated in a cross-sectional study, including assessments of demographics, family functioning, child behavioral health symptoms, and health related pediatric quality of life (HRQOL). Bivariate correlations, independent samples t-test, and linear and logistic regression tested associations of parent and child reported family functioning with child behavioral health symptoms and HRQOL. Results: Parent and child reports of family functioning were significantly associated. Child, but not parent reports of family functioning were significantly associated with parent and child reports of behavioral health symptoms. Parent's reports of increased family functioning impairment were only significantly associated with parent's reports of decreased HRQOL. Family functioning impairment was associated with parent and child reports of increased behavioral health symptoms and decreased HRQOL. Conclusion: Future work should determine if screening for family functioning impairment, may serve as a means of identifying and treating child behavioral health symptoms in Family Medicine. Practice Implications: Identifying impaired family functioning may serve to engage children and their parents in services, who may otherwise not be identified as having symptoms. (C) 2021 Elsevier Inc. All rights reserved.

National guidelines and quality measures use the presence of genitourinary (GU) symptoms to distinguish between acute urinary tract infection (UTI) and asymptomatic bacteriuria (ASB). As a result, understanding the accuracy of chart documentation is critical to ensuring validity of research studies and antimicrobial stewardship programs.1-3 Most studies evaluating UTI in older emergency department (ED) patients relied on electronic medical record (EMR) documentation as the criterion standard for the presence of symptoms.3-8 Our goal was to investigate the accuracy of chart abstraction versus direct ED patient interview for the presence of GU symptoms. We used patient self-report as the criterion standard. This was a preplanned secondary analysis of patients in an observational study conducted at an urban tertiary care teaching hospital ED and an affiliated urban community hospital ED. Enrollment is ongoing for the parent study (National Institutes of Health R01AG050801), whose objective is to identify urinary immune system biomarkers to improve UTI diagnostic accuracy.9 Subjects in this analysis were enrolled from October 30, 2016, to December 17, 2018. ED adults aged 65 and older who had a urinalysis ordered for clinical care were the study population because knowing the presence or absence of GU symptoms is pivotal to the clinical decision to treat bacteriuria with antibiotics in this population. Exclusion criteria (designed for the parent study) included chronic or intermittent catheterization, recent UTI or positive urine culture (prior 30 days), GU procedure (prior 30 days), antibiotic use (prior 14 days), hemodialysis, immunosuppression (active cancer or taking immunosuppressants or steroids in the prior 30 days), homelessness, previous enrollment, current incarceration, non–English speaking, trauma team activation, and lack of patient or proxy ability to give consent or respond to the survey. Each patient was asked, “In the past 24 hours have you had new or worsening [symptom]?” for each symptom. Symptoms were taken from national guidelines and included GU symptoms (dysuria, frequency, suprapubic pain, gross hematuria, flank pain, and incontinence), as well as nonspecific symptoms (fever, malaise/lethargy, and confusion/altered mental status).10-13 As a control, we collected data on other symptoms: nausea, vomiting, and abdominal pain. Trained abstractors blinded to the study hypothesis used a standardized form and code book to record data from the EMR (Epic, Epic Systems, Inc, Verona, WI) including demographics, medical history, and presence or absence of symptoms. We compared the presence of patient-reported and chart review–reported symptoms using McNemar's chi-square test. Holm's methods of adjustment was used to account for multiple outcomes. Agreement between patient report and chart documentation was calculated using the κ statistic with 95% confidence intervals (CIs). Of 2,588 subjects screened for enrollment, 1,852 were excluded for catheter use (n = 130), recent UTI (148), recent GU procedure (17), recent antibiotics (674), on hemodialysis (69), immunocompromised (800), trauma (7), incarcerated (3), and homeless (4). Among 736 eligible patients, reasons for nonenrollment included patient refusal (n = 296), patient too ill or with altered mental status (115), non–English speaking (33), and missed by research assistant (28), leaving 264 subjects for analysis. Median age was 74 years (interquartile range [IQR] = 69–81 years), and 64% were female. Median Charlson Comorbidity Index was 6 [IQR = 4–8] with 20% (n = 52) with dementia and 8% (n = 20) with delirium. Antibiotics were administered in 88 (33%), and 184 (69.7%) were admitted. Urine cultures were positive for one to two pathogens at higher than 1,000 cfu/mL in 72 (27%) patients. At least one GU symptom was reported by 185 (70%; 95% CI = 64–76%) of patients, but GU symptoms were only chart documented in 103 (39%; 95% CI = 33–45%) (P < .001) (Table 1). All GU symptoms were underdocumented in ED charts except for dysuria. Agreement for GU and nonspecific symptoms ranged from 53% to 95% with only dysuria and gross hematuria having 80% or higher agreement. The κ values demonstrated poor or fair agreement for GU symptoms. Sensitivity of chart documentation was correspondingly poor, ranging from 16.4% for suprapubic pain to 55% for confusion/altered mental status, but specificity was high. We found that patient self-report identified the presence of significantly more new or worsening GU symptoms than chart review. This is consistent with one prior inpatient study.14 Prior ED studies generally reported rates of symptoms as low as 30% among those diagnosed with UTI, raising concerns that EDs treat a substantial proportion of patients with ASB.4, 7 However, we found that chart review significantly underestimated GU symptoms among older adults in the ED with suspected UTI. We conclude that caution should be used when phenotyping these patients using chart review data for research or administrative purposes and that the problem of treatment of ASB in older ED adults may be overstated. We appreciate Michael Hill, RN, research manager, for his support and assistance with the conduct of this study. This work was funded by Grant No. R01AG0508001 from the National Institutes of Health. The authors have declared no conflicts of interest for this article. The funder was not involved in the design, methods, subject recruitment, data collection, analysis, or preparation of the article. Conceived the study topic and obtained funding: Caterino, Schwaderer, Hains, and Carmargo. Performed the gold standard criterion evaluations. Southerland, Bischof, and Hebert. Conceived the analysis plan and performed the analyses: Stephens and Wei. Assisted with data interpretation and critically reviewed the manuscript: Wexler, Hunold, and Wolfe. Critically reviewed and edited the manuscript: All authors.

Objective: To evaluate the effectiveness of nutrition counseling for patients with hypertension, provided in a grocery store setting. Design: Single-arm pretest-posttest design implementing a 12-week dietary intervention. Setting: Grocery store. Participants: Thirty adults with hypertension recruited from a primary care practice. Intervention: Registered dietitian nutritionists provided counseling based on the Dietary Approaches to Stop Hypertension diet. Main Outcome Measures: Dietary intake patterns and Healthy Eating Index-2010 (HEI-2010) scores measured via food-frequency questionnaire. Change in systolic blood pressure (SBP) was a secondary outcome. Analysis: Paired t tests were used to test for differences between HEI-2010 scores, intake of key food pattern components, and SBP at baseline compared with follow-up. Statistical significance was established at P <= .05. Results: Eight HEI-2010 component scores increased significantly from baseline to follow-up (a change toward a more desirable eating pattern): total fruit, whole fruit, greens and beans, whole grains, fatty acids, refined grains, and empty calories. Sodium (P < .001), saturated fat (P < .001), discretionary solid fat (P < .001), added sugars (P = .01), and total fat (P < .001) all decreased significantly. The change in SBP was not significant. Conclusions and Implications: Grocery store-based counseling for patients with hypertension may be an effective strategy to provide lifestyle counseling that is not typically available within primary care.

Background: Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited. Objective: To determine how the implementation of a teledermatology program affects access to health care and patient outcomes. Methods: A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period. Results: Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P<.001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P<.001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either ``no-shows'' (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 +/- 79.8 vs 116.9 +/- 86.6 days; P = .004). Conclusion: Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

Palpitations are a common problem in the ambulatory primary care setting, and cardiac causes are the most concerning etiology. Psychiatric illness, adverse effects of prescription and over-the-counter medications, and substance use should also be considered. Distinguishing cardiac from noncardiac causes is important because of the risk of sudden death in those with an underlying cardiac etiology. A thorough history and physical examination, followed by targeted diagnostic testing, can distinguish cardiac conditions from other causes of palpitations. Persons with a history of cardiovascular disease, palpitations at work, or palpitations that affect sleep have an increased risk of a cardiac cause. A history of cardiac symptoms, a family history concerning for cardiac dysrhythmias, or abnormal physical examination or electrocardiography findings should prompt a more in-depth evaluation for heart disease. Ischemic symptoms may signal coronary heart disease and associated ventricular premature contractions that may warrant exercise stress testing. Exertional symptoms accompanied by elevated jugular venous pressure, rales, or lower extremity edema should raise concern for heart failure; imaging may be required to assess for functional and structural heart disease.

IntroductionNutrition counseling is an important intervention for many chronic diseases and dietary assessment is a crucial component of any initial nutrition counseling visit. Although necessary, the process of collecting a detailed dietary assessment is time consuming and, in turn, decreases the amount of time available for nutrition education and goal setting. The objective of this study was to examine whether an online dietary assessment completed prior to a nutrition counseling visit was related to more efficient nutrition counseling visits.MethodsTwenty‐six adults were recruited out of primary care centers and were randomized to either the pre‐assessment group (n=13) or the control group (n=13). Participants in both groups then attended 2 nutrition counseling visits with registered dietitians in a local grocery store. The pre‐assessment group completed an online food frequency questionnaire prior to their first visit with the dietitian, to which the dietitian had access prior to the initial visit. The control group did not complete a dietary assessment before their visit. Following each visit, the dietitians reported the time spent on assessment, education, goal setting, and aisle tours, as well as the specific topics covered during the education portion. A depth score was also used to estimate the average depth of each of the topic covered in the session (1=basic introduction, 4=skill mastery activities).ResultsParticipants who completed the online dietary assessment questionnaire experienced a more in‐depth nutrition educational experience as a result of the detailed preliminary report. When compared to the control group, the provision of the dietary intake assessment questionnaire resulted in significantly less time spent on assessment (14 vs. 19 minutes) and significantly more time spent on education (33 vs. 26 minutes) and goal setting (13 vs. 11 minutes) during the initial 1 hour session. Although the dietitians reported a shorter time spent on dietary assessment during the visit, they also reported spending an average of 13 minutes reviewing the online assessments prior to the visit. Those who completed the assessment prior to their visits had a greater mean number of topics covered, as well as a greater average depth score.DiscussionCompleting a dietary assessment prior to the initial nutrition counseling visit allowed for a more efficient visit with the dietitian. More time was spent on education and goal setting and the breadth and depth of the initial visit was greater for those in the pre‐assessment group. Requesting that patients complete a detailed dietary assessment prior to their nutrition counseling visits may be a feasible method for improving nutrition care, however additional research testing this model on a wider scale is necessary.Support or Funding InformationThe Ohio State University Food Innovation Center

Objective: Age at first atherosclerotic event is typically older for women vs. men; monthly iron loss has been postulated to contribute to this advantage. We investigated the relationship between an MRI-based arterial wall biomarker and the serum inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) in perimenopausal women vs. men.Methods and Results: Women without evident atherosclerotic disease were prospectively enrolled and observed over 24 months of menopause transition, indicated by hormone levels and reduction in median number of menstrual cycles from 4 [3-6] per year to 0 [0-1] per year (P < 0.01). Higher hsCRP predicted shorter carotid artery wall T2* in women entering the menopause transition (r = -0.3139, P = 0.0014); this relationship weakened after 24 months of perimenopause in women (r = -0.1718, P = 0.0859) and was not significant in a cohort of men matched for age and cardiovascular risk category (r = -0.0310, P = 0.8362). Serum ferritin increased from baseline to 24-month follow-up during women's menopause transition (37 [20-79] to 67 [36-97] ng/mL, P < 0.01), but still remained lower compared to men (111 [45 -220] ng/mL, P < 0.01). Circulating ferritin levels correlated with arterial wall T2* values in women at baseline (r = -0.3163, P = 0.0013) but not in women after 24 months (r = -0.0730, P = 0.4684) of menopause transition nor in men (r = 0.0862, P = 0.5644).Conclusions: An arterial wall iron-based imaging biomarker reflects degree of systemic inflammation in younger women, whereas this relationship is lost as women transition through menopause to become more similar to men. Iron homeostasis and inflammation in the arterial wall microenvironment warrants further investigation as a potential early target for interventions that mitigate atherosclerosis risk. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Background: Inappropriate emergency department (ED) use among Medicaid enrollees is considered a problem because of cost. We developed and evaluated a system change innovation designed to remove system barriers to primary care access for Medicaid patients. Methods: Patients who presented to the ED without an identified primary care provider were randomized to the intervention (n = 72) or comparison group (n = 68) for a 12-month study designed to connect these patients to primary care offices. Evaluation was mixed quantitative/qualitative. Results: Significantly more intervention participants attended at least 1 primary care visit 3 months after the intervention (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.06–6.02), though this difference was not significant by 12 months (OR, 1.74; 95% CI, 0.79–3.84). The intervention participants also did not have lower odds of returning to the ED for nonurgent reasons by the 12-month follow-up (OR, 1.27; 95% CI, 0.65–2.48). Patient-reported barriers to attending a primary care appointment were primarily social and health system–related factors. Conclusion: The intervention did not decrease ED visits nor increase primary care use over the 12 months of the study period. The qualitative results provide insight into nonurgent ED utilization by patients with Medicaid, suggesting potential future interventions.

Objective: This paper examines differences in characteristics of food pantry clients using an Emergency Department (ED) versus a Primary Care Provider (PCP) for primary healthcare. Methods: Data from a 2012-13 survey at 5 food pantries (N = 251 adults) were evaluated. Socio-demographics, insurance coverage, financial trade-offs and services, chronic diseases, health perceptions, and behaviors were stratified by healthcare source. Inferential statistics were employed to evaluate differences across the primary source of healthcare. Results: ED users engaged in high-risk health behaviors and significantly lower rates of preventive health screenings. The ED cohort reported significantly poorer perceptions of health and lower prevalence of disease. Conclusions: Food pantry clients that utilized a PCP reported better health outcomes and behaviors, supporting efforts for continued care in this highly vulnerable and underserved population.