Development of a clinician guide for electronic medication adherence products in older adults.

Background/objectives: The ability to manage medications independently may be affected in older adults due to physical and cognitive limitations. Numerous electronic medication adherence products (eMAPs) are available to aid medication management. Unfortunately, there are no available guidelines to support clinicians in recommending eMAPs. The objective of this study was to create and validate a clinician tool to guide use of eMAPs. Methods: Pharmacists who previously tested the usability of the eMAPs participated in a focus group to provide feedback on 5 metrics of the clinician guide: unassisted task completion, efficiency, usability, workload and an overall eMAP score. Participants were asked semistructured questions on how they would use the tool to inform recommendations of medication aids to patients. The discussions were audio-recorded and transcribed verbatim and qualitatively analyzed. The clinician guide was modified to reflect feedback. Results: Five pharmacists (80% female, mean years of practice: 15.8) participated in the focus group. The clinician guide was modified by removing 2 metrics and adding an additional 8 metrics: maximum number of alarms, number of days the product can accommodate for based on a daily dosing regimen, price, monthly subscription, portability, locking feature, average time to set the device and number of steps required to set the device. The definition and calculation for unassisted task completion were modified. Additional instructions and specific patient case examples were also included in the final clinician guide. Conclusion: Since significant variability exists between eMAPs, it is imperative to have a tool for frontline clinicians to use when appropriately recommending the use of these products for medication management in older adults.

A Prospective Study of Usability and Workload of Electronic Medication Adherence Products by Older Adults, Caregivers, and Health Care Providers.

BACKGROUND: A decreased capacity to self-manage medications results in nonadherence, medication errors, and drug-related problems in older adults. Previous research identified 80 electronic medication adherence products available to assist patients with self-management of medications. Unfortunately, the usability and workload of these products are unknown. OBJECTIVE: This study aimed to examine the usability and workload of a sample of electronic medication adherence products. METHODS: In a prospective, mixed methods study, a sample of older adults, health care professionals, and caregivers tested the usability and workload of 21 electronic medication adherence products. Each participant tested 5 products, one at a time, after which they completed the system usability scale (SUS) and NASA-task load index (NASA-TLX), instruments that measure the usability and workload involved in using a product. Higher SUS scores indicate more user-friendliness, whereas lower NASA-TLX raw scores indicate less workload when using a product. RESULTS: Electronic medication adherence products required a mean of 12.7 steps (range 5-20) for the appropriate use and took, on average, 15.19 min to complete the setup tasks (range 1-56). Participants were able to complete all steps without assistance 55.3% of the time (103 out of the 186 tests were completed by 39 participants; range 0%-100%). The mean SUS and NASA-TLX raw scores were 52.8 (SD 28.7; range 0-100) and 50.0 (SD 25.7; range 4.2-99.2), respectively, revealing significant variability among the electronic medication adherence products. The most user-friendly products were found to be TimerCap travel size (mean 78.67, SD 15.57; P=.03) and eNNOVEA Weekly Planner with Advanced Auto Reminder (mean 78.13, SD 14.13; P=.049) as compared with MedReady 1700 automated medication dispenser (mean 28.63, SD 21.24). Similarly, MedReady (72.92, SD 18.69) was found to be significantly more work intensive when compared with TimerCap (29.35, SD 20.35; P=.03), e-pill MedGlider home medication management system (28.43, SD 20.80; P=.02), and eNNOVEA (28.65, SD 14.97; P=.03). The e-pill MedTime Station automatic pill dispenser with tipper (71.77, SD 21.98) had significantly more workload than TimerCap (P=.04), MedGlider (P=.03), and eNNOVEA (P=.04). CONCLUSIONS: This study demonstrated that variability exists in the usability and workload of different electronic medication adherence products among older adults, caregivers, and clinicians. With few studies having investigated the usability and workload of electronic medication adherence products, no benchmarks exist to compare the usability and workload of these products. However, our study highlights the need to assess the usability and workload of different products marketed to assist with medication taking and provides guidance to clinicians regarding electronic medication adherence product recommendations for their patients. Future development of electronic medication adherence products should ensure that the target populations of patients are able to use these products adequately to improve medication management.

Skin decontamination of Carfentanil in vitro.

Skin decontamination of Chemical Biological Radioactive and Nuclear (CBRN) materials involves the timely and effective removal of the contaminants from the skin surface. The current work evaluated Fuller's Earth & The Reactive Skin Decontaminant Lotion Kit (RSDL®) to investigate whether they were as efficacious against free base Carfentanil skin contamination as they are against chemical warfare agents. The in vitro methodology used allowed for evaluation of decontamination regimens as specified by the decontaminant manufacturer rather than as an application of a bolus dose left in situ for the study duration. A selection of novel decontaminants, including Dermal Decontamination Gel (DDGel), Trivorex®, itaconic acid (IA), N,N'-methylenebisacrylamide (MBA), 2-trifluoromethylacrylic acid (TFMAA) and NanoSan Sorb were also tested for efficacy. All the evaluated decontaminants were successful at removing the majority of the Carfentanil skin surface contamination. The current work has shown that the Fuller's Earth decontamination kit, removes as much (or more) free base carfentanil from the skin surface in comparison to other products tested in this study series.

Percutaneous absorption of Carfentanil in vitro.

Carfentanil is a synthetic opioid restricted to veterinary use due to its potency. Public health concerns have been raised as to the potential of carfentanil to exhibit toxicity after absorption via the percutaneous route following unintentional contamination. The current study measured the penetration of free base carfentanil through human, pig and rat skin using in vitro static diffusion cells. The human penetration rates were compared against literature toxicology values and indicated that, dependent on the contamination density, contamination area and residence time, skin decontamination and medical countermeasures may be required to ameliorate toxicity. The pig and rat skin penetration data will form the basis of future work to develop relevant in silico and in vivo models to further elucidate likely toxic effects and the medical strategies to mitigate against them.

Development and Content Validation of an Instrument to Measure Medication Self-Management in Older Adults.

BACKGROUND: For older adults, the capacity to self-manage medications may be limited by several factors. However, currently available tools do not permit a comprehensive assessment of such limitations. The Domain Specific Limitation in Medication Management Capacity (DSL-MMC) was developed to address this need. This study aimed to establish the face and content validity of the DSL-MMC. METHODS: The DSL-MMC tool consisted of 4 domains and 12 sub-domains with 42 items including: 1. physical abilities (vision, dexterity, hearing); 2. cognition (comprehension, memory, executive functioning); 3. medication regimen complexity (dosing regimen, non-oral administration, polypharmacy); and 4. access/caregiver (prescription refill, new prescription, caregiver). Pharmacists assessed each item for relevance, importance, readability, understandability, and representation. Items with content validity index (CVI) scores of <0.80 for relevance were examined for revision or removal. RESULTS: Twelve pharmacists participated in the study. CVI scores for relevance and importance of domains were 1.0; of the sub-domains, two were below 0.80. Among the 42 items, 35 (83%) and 30 (71%) maintained CVI scores above 0.80 for relevance and importance, respectively. Five items were removed, three were merged and seven were modified due to low CVI scores and/or feedback. CONCLUSION: The DSL-MMC has been validated for content.

Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia.

AIM: This study pilot-tested the person-centered risk assessment framework (PCRAF), a framework for managing risk among persons living with dementia (PLWD) in primary care. METHODS: Healthcare providers (N = 7) piloting the PCRAF completed a survey, rating their satisfaction with the tool, and an interview to gather their perceptions of the PCRAF. PLWD and care partners (N = 12) completed a survey, rating their satisfaction with safety planning. RESULTS: Care providers were very satisfied with the tool; however, patient or care partner inability to perceive or understand safety risks was a challenge. Use of the PCRAF was perceived as an opportunity to empower self-management, gather PLWD and care partner perspectives, reduce burden for care partners and increase understanding of potential risks. Patients and care partners were very satisfied with the way in which they were included in the risk discussion. CONCLUSION: The PCRAF is a promising new tool to reduce risks associated with dementia.

CD147 Promotes Entry of Pentamer-Expressing Human Cytomegalovirus into Epithelial and Endothelial Cells.

Human cytomegalovirus (HCMV) replicates in many diverse cell types in vivo, and entry into different cells involves distinct entry mechanisms and different envelope glycoproteins. HCMV glycoprotein gB is thought to act as the virus fusogen, apparently after being triggered by different gH/gL proteins that bind distinct cellular receptors or entry mediators. A trimer of gH/gL/gO is required for entry into all cell types, and entry into fibroblasts involves trimer binding to platelet-derived growth factor receptor alpha (PDGFRα). HCMV entry into biologically relevant epithelial and endothelial cells and monocyte-macrophages also requires a pentamer, gH/gL complexed with UL128, UL130, and UL131, and there is evidence that the pentamer binds unidentified receptors. We screened an epithelial cell cDNA library and identified the cell surface protein CD147, which increased entry of pentamer-expressing HCMV into HeLa cells but not entry of HCMV that lacked the pentamer. A panel of CD147-specific monoclonal antibodies inhibited HCMV entry into epithelial and endothelial cells, but not entry into fibroblasts. shRNA silencing of CD147 in endothelial cells inhibited HCMV entry but not entry into fibroblasts. CD147 colocalized with HCMV particles on cell surfaces and in endosomes. CD147 also promoted cell-cell fusion induced by expression of pentamer and gB in epithelial cells. However, soluble CD147 did not block HCMV entry and trimer and pentamer did not bind directly to CD147, supporting the hypothesis that CD147 acts indirectly through other proteins. CD147 represents the first HCMV entry mediator that specifically functions to promote entry of pentamer-expressing HCMV into epithelial and endothelial cells.IMPORTANCE Human cytomegalovirus infects nearly 80% of the world's population and causes significant morbidity and mortality. The current method of treatment involves the use of antiviral agents that are prone to resistance and can be highly toxic to patients; currently, there is no vaccine against HCMV available. HCMV infections involve virus dissemination throughout the body, infecting a wide variety of tissues; however, the mechanism of spread is not well understood, particularly with regard to which cellular proteins are utilized by HCMV to establish infection. This report describes the characterization of a newly identified cellular molecule that affects HCMV entry into epithelial and endothelial cells. These results will lead to a better understanding of HCMV pathogenesis and have implications for the development of future therapeutics.

A randomised trial of the impact of energy density and texture of a meal on food and energy intake, satiation, satiety, appetite and palatability responses in healthy adults.

BACKGROUND & AIMS: Texture modified diets may be enriched to optimise the opportunity for individuals to meet their required energy intakes; however there is insufficient evidence supporting this strategy. Thus we sought to investigate the effect of texture and energy density on food (g) and energy intakes (kcal), appetite (satiation and satiety), and palatability in healthy adults. METHODS: A single blind within-subjects randomised crossover design, where 33 healthy adults consumed a test meal with either its texture and/or energy density altered, until satiation was reached whilst rating their appetite parameters. Subsequent intakes were recorded in a food diary to determine the effect of the treatments on satiety and identify any evidence of energy compensation. RESULTS: Test meal energy intakes (kcal) were significantly higher with energy enrichment of both meals (standard texture; 315 kcal and texture modified; 303 kcal (p = 0.001)) and remained higher over the day for both (260 kcal/d and, 225 kcal/d respectively (p < 0.05)). Area under the curve (AUC) did not differ between meals for hunger, fullness, or desire to eat however palatability was significantly reduced with texture modification. CONCLUSIONS: Enriching meals (standard texture and texture modified) is an effective method to increase short term energy intakes in healthy adults over a 24 h period and may have application to optimise energy intakes in a clinical setting.

Community-based falls prevention: lessons from an Interprofessional Mobility Clinic.

Falls are a common and serious risk with an aging population. Chiropractors commonly see firsthand the effects of falls and resulting injuries in their senior patients and they can reduce falls risk through active screening. Ongoing research has provided proven approaches for making falls less likely. Screening for falls should be done yearly for all patients 65 years and older or in those with a predisposing medical condition. Additional specific falls prevention professional education would enable the chiropractor to best assist these patients. Collaboration and communication with the patient's family physician offers an opportunity for improved interprofessional dialogue to enhance patient care related to falls risk. Frequently falls prevention strategies are implemented by an interprofessional team. Chiropractors increasingly contribute within multidisciplinary teams. Collaboration by the chiropractor requires both simple screening and knowledge of health care system navigation. Such awareness can permit optimal participation in the care of their patient and the best outcome.

Les chutes présentent un risque commun et grave chez une population vieillissante. Les chiropraticiens constatent habituellement directement les effets des chutes et les blessures conséquentes chez leurs patients âgés; et ils peuvent en réduire les risques grâce à un dépistage actif. Des recherches continues fournissent des méthodes vérifiées de réduction de la probabilité de chutes. Un dépistage des risques de chute doit être effectué chaque année pour tous les patients de 65 ans et plus, ou pour ceux dont l'état de santé les prédispose. Une formation professionnelle supplémentaire spécifique dans la prévention des chutes permettrait au chiropraticien de mieux aider ces patients. La collaboration et la communication avec le médecin de famille du patient offrent une occasion d'améliorer le dialogue interprofessionnel au profit de meilleurs soins prodigués au patient sur les risques de chute. Souvent les stratégies en matière de prévention des chutes sont mises en place par une équipe interprofessionnelle. Les chiropraticiens œuvrent de plus en plus au sein d'équipes multidisciplinaires. La collaboration des chiropraticiens nécessite des compétences pour de simples dépistages, ainsi que des connaissances pour s'orienter dans le système des soins de santé. De telles connaissances permettront au chiropraticien une participation optimale aux soins de son patient et l'obtention des meilleurs résultats.

A review of cutaneous drug eruptions.

Cutaneous drug eruptions can range from an asymptomatic rash to a life-threatening emergency. Because of the high frequency, morbidity, and potential mortality associated with drug eruptions, patients with possible drug reactions should promptly be recognized, worked up, and treated. Drug reactions are common in the elderly population due to age-related alterations in metabolism, excretion of medications, and polypharmacy. This review discusses the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of drug eruptions that providers commonly encounter in the care of the geriatric population. An algorithm for an approach to patients with a suspected drug eruption is presented.

The effect of luminance on simulated driving speed.

Perceived speed is modulated by a range of stimulus attributes such as contrast, luminance and adaptation duration. It has been suggested that such changes in perceived speed may influence driving behaviour. In order to evaluate the effect of luminance on driving speed we have measured subjects' driving speed in a driving simulator for a range of luminance and speed over time. The results indicate that reducing luminance results in a decrease in driving speed for all speeds measured. This reduction in driving speed at low luminance is consistent with previous findings that perceived speed increases at low luminance. However, the results also indicated that driving speed remained stable over a 30s period. The stability of driving speed over time is inconsistent with previous findings that perceived speed reduces exponentially as a function of adaptation duration. The results are suggestive of a scheme whereby driving speed is consistent with the known effects of luminance upon perceived speed but may also be modulated by higher order processes that serve to maintain a constant speed over time.

Germination and storage reserve mobilization are regulated independently in Arabidopsis.

The phytohormone abscisic acid (ABA) inhibits the germination of many seeds, including Arabidopsis, but the mechanism for this is not known. In cereals, ABA inhibits the expression of genes involved in storage reserve mobilization. We have found that in Arabidopsis ABA decreases transcription from the promoters of marker genes for beta-oxidation and the glyoxylate cycle, essential pathways for the conversion of storage lipid (triacylglycerol) into sucrose. Thirty per cent of stored lipid is broken down over 6 days following imbibition of ABA-treated seed. Sucrose levels in ABA-treated seeds, rather than decreasing as under normal growth conditions, actually double during the 3 days following imbibition. This sucrose is derived from triacylglycerol as demonstrated by two mutants disrupted in the conversion of triacylglycerol into sucrose, kat2 and icl1, which do not accumulate sucrose in the presence of ABA. We conclude that the ABA block on germination is not a consequence of inhibition of storage lipid mobilization. Two independent programmes appear to operate, one that is blocked by ABA, governing developmental growth resulting in germination; and a second that governs storage lipid mobilization which is largely ABA-independent.