Frequent acquisition of low-virulence strains of ESBL-producing Escherichia coli in travellers.

OBJECTIVES: International travel is a risk factor for intestinal colonization with ESBL-producing Enterobacteriaceae (EPE). This prospective cohort study focuses on molecular features of and risk factors for travel-acquired EPE. METHODS: Rectal swabs and survey data were collected from 188 Swedes travelling to four regions of high EPE prevalence. Samples were plated onto selective agars. ESBL producers were determined using phenotypic methods. Molecular characterization regarding virulence factors and phylogenetic grouping of ESBL-producing Escherichia coli was done using PCR. Isolates were also screened for the plasmid-mediated colistin resistance gene mcr-1. RESULTS: Among 175 pre-travel EPE-negative participants, 32% were positive upon return. No carbapenemase-producing Enterobacteriaceae were found, but one CTX-M-producing E. coli harboured mcr-1 (travel to Thailand). Most E. coli strains (43.1%) belonged to phylogroup A and were rarely associated with extraintestinal infections and a few (9.2%) expressed uropathogenicity pap genes. During 10-26 months of follow-up, no clinical infections were observed. Colonization rates varied by visited region: the Indian subcontinent, 49.2%; northern Africa, 44.0%; South-East Asia, 19.1%; and Turkey, 9.5%. Travellers' diarrhoea (OR 2.5, P = 0.04) or antimicrobial treatment during the trip (OR 5.9, P = 0.02) were both independent risk factors for EPE colonization. CONCLUSIONS: EPE acquired during travel have seemingly low pathogenicity, possibly indicating a low risk of clinical infection. Pre-travel advice should emphasize avoiding unnecessary antibiotic treatment during travel.

Update on managing generalized anxiety disorder in older adults.

With the recent updates to the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), there are many questions on how to care for older adults with generalized anxiety disorder (GAD) and other psychiatric conditions. The current article reviews the new changes to the DSM-5 for diagnosis of GAD, discusses new anxiety assessment scales that are validated in older adults, evaluates pharmacological agents that have been studied in older adults for GAD treatment, and provides monitoring recommendations to help those who provide care to older adults experiencing GAD.

Mirtazapine-Associated Hypertriglyceridemia and Hyperglycemia.

The patient is a 75-year-old male who was admitted to the long-term care unit because of advancing dementia and was being treated with mirtazapine to improve his mood and stimulate his appetite. This case report outlines an interesting occurrence of hypertriglyceridemia followed by hyperglycemia, which resembled diabetes mellitus and required insulin therapy. The patient continued to have elevated triglyceride levels that persisted despite discontinuation of mirtazapine therapy.

Use of an interactive trivia game to increase knowledge and awareness of appropriate antibiotic use in community-dwelling older adults: a pilot survey.

OBJECTIVE: To assess change in knowledge and awareness of upper respiratory-tract infections (URTIs), and appropriate antibiotic use in community-dwelling older adults. DESIGN: Single group, pre- and post-test study. SETTING: Two independent senior living communities in Baltimore City and Baltimore County, Maryland. PARTICIPANTS: Older adults eligible to receive housing or other social services as defined by the study sites. INTERVENTION: Use of an interactive trivia game to educate older adults about URTIs. A 15-item pre- and postsurvey was administered to assess change in knowledge. OUTCOME MEASURES: Average change in pre- and postsurvey scores. RESULTS: Thirty-two seniors participated in the game intervention, with 18 completing both surveys. There was no significant difference in the total mean pre- versus postsurvey scores. Average scores of pre- and postsurveys were 9.28 and 9.17, respectively, out of 15 points (95% confidence interval 0.65 +/- 1.414; P = 0.76). Upon review of individual survey questions, two specific areas showed a significant improvement on postsurvey scores compared with baseline. Participants showed significant improvement, however, in knowledge regarding symptoms that may require the use of an antibiotic (P = 0.02) and symptomatic management of URTI symptoms (P = 0.045). CONCLUSIONS: Based on survey results, we learned more about older adults' knowledge regarding URTIs, antibiotic use, and strategies to provide education to community-dwelling geriatric adults. The game was effective in teaching older adults about symptom management and symptoms that may require an antibiotic.

Towards a comprehensive characterization of spatio-temporal dependence of light-induced electromagnetic forces in dielectric liquids.

The interaction of localized light with matter generates optical electrostriction within dielectric fluids, leading to a discernible change in the refractive index of the medium according to the excitation's light profile. This optical force holds critical significance in optical manipulation and plays a fundamental role in numerous photonic applications. In this study, we demonstrate the applicability of the pump-probe, photo-induced lensing (PIL) method to investigate optical electrostriction in various dielectric liquids. Notably, the thermal and nonlinear effects are observed to be temporally decoupled from the electrostriction effects, facilitating isolated observation of the latter. Our findings provide a comprehensive explanation of optical forces in the context of the recently introduced microscopic Ampère electromagnetic formalism, which is grounded in the dipolar approximation of electromagnetic sources within matter and characterizes electrostriction as an electromagnetic-induced stress within the medium. Here, the optical force density is re-obtained through a new Lagrangian approach.

Moving beyond warfarin-are we ready? A Review of the efficacy and safety of novel anticoagulant agents compared to warfarin for the management of atrial fibrillation in older adults.

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias seen in clinical practice. Stroke risk in patients diagnosed with AF increases from 1.5% in the fifth decade of life to 23.5% in patients older than 80, emphasizing the need for effective and appropriate therapies. Over the past 50 years, vitamin K antagonists-namely warfarin (Coumadin(®))-have been the mainstay for stroke prevention. The introduction of dabigatran (Pradaxa(®)), rivaroxaban (Xarelto(®)), and apixaban (Eliquis(®)) has caused both patients and providers to question whether better alternatives to warfarin therapy exist. These agents have shown to be at least as effective as warfarin in stroke risk reduction with no need for international normalized ratio monitoring. This review will examine these newer anticoagulant agents' safety and efficacy and provide clinical considerations for treating older adults with AF. Clinicians with patients unable to tolerate warfarin or with difficulty managing therapy will need to consider patient characteristics, cost, adherence, lack of a reversal agent, and long-term efficacy before prescribing these agents.

Diversification and Expansion of Clinical Pharmacy Services: Is it Time for Senior Care Pharmacists to Step Into the Light?

According to the American Board of Medical Specialties, there were 7,123 certified geriatricians practicing in the United States in 2021. The Health Resources and Services Administration estimates a shortage of 27,000 geriatricians in 2025. Only 43% of geriatrics fellowship spots were filled in 2022. With this forthcoming decrease in medical providers, the role of the senior care pharmacist must expand and diversify to provide an equitable level of care that older patients will need-especially with the expansion of antipsychotic, antimicrobial, and opioid stewardship programs. Senior care pharmacists possess a diverse range of skills and knowledge that are indispensable to the health care team. It is time to move beyond the consultant role, expanding both clinically and operationally, to provide the quality health care that older patients need.

Chronic Obstructive Pulmonary Disease, Part 5: Clinical Pearls for Comorbid COPD.

Chronic obstructive pulmonary disease (COPD) is often diagnosed with other comorbid conditions. This can complicate therapy overall by contributing to adverse events leading to poor outcomes to not only COPD, but other comorbid conditions. This manuscript will discuss common comorbid conditions often seen with COPD, update vaccination recommendations for COPD patients, and provide information regarding smoking cessation in COPD. The senior care pharmacist has an important role where they can recommend medication adjustments to potentially avoid these adverse events, immunize their patients appropriately, and provide assistance with smoking cessation to improve not only COPD outcomes but outcomes associated with other comorbid conditions.

The Essential Role of Senior Care Pharmacists in Antimicrobial Stewardship: An Updated Position Statement on Behalf of the American Society of Consultant Pharmacists and the Society of Infectious Diseases Pharmacists.

Senior care pharmacists are well-positioned to lead and drive antimicrobial stewardship (AMS) initiatives, not only through audit and data collection, but also through communication, collaboration, and cooperation with prescribers and nurses to influence prescribing behaviors. Senior care pharmacists are in a unique position to take a leadership role within the interprofessional team to achieve AMS goals. They should engage with the interprofessional team to promote the judicious and appropriate use of antimicrobials at their practice sites. This position statement is an update of the 2017 version by the American Society of Consultant Pharmacists (ASCP) Antimicrobial Stewardship and Infection and Prevention Control Committee and the Society of Infectious Diseases Pharmacists (SIDP).

Helix-dipole effects in peptide self-assembly to amyloid.

The formation of amyloid fibrils is associated with incurable diseases including Alzheimer's, Parkinson's, and type 2 diabetes. Important mechanistic details of the self-assembly are unknown partly because of the absence of a clear structural characterization of intermediates. There is experimental evidence, however, for α-helical intermediates that has come primarily from circular dichroism spectroscopy. Here, we strengthen the evidence for helical intermediates by demonstrating helix-dipole effects in the early events of self-assembly. Previously, we showed that capped peptides containing the part of the islet amyloid polypeptide that may be responsible for the initial intermolecular contacts (Acetyl-R(11)LANFLVHSSNNFGA(25)-NH(2) and Acetyl-R(11)LANFLVHSGNNFGA(25)-NH(2) which contains the S20G mutation associated with early onset type 2 diabetes) self-assemble via helical intermediates [Liu et al. (2010) J. Am. Chem. Soc.132, 18223-18232]. We demonstrate here that when the peptides are uncapped, they do not self-assemble as indicated primarily by circular dichroism and nuclear magnetic resonance data. Self-assembly is restored when the charge on α-NH(3)(+) of Arg11 is eliminated but not when the charge on α-COO(-) of Ala25 is removed, consistent with the helicity of the peptides skewed toward the N-terminus. Our results strengthen the hypothesis that α-helical intermediates are on pathway to amyloid formation and indicate that the helix dipole is an attractive target for inhibiting the formation of α-helical assemblies.

Long-term treatment of invasive sinus, tracheobroncheal, pulmonary and intracerebral aspergillosis in acute lymphoblastic leukaemia.

A 59-year-old male with acute lymphoblastic leukemia developed sinus, tracheobroncheal, pulmonary, and intracerebral aspergillosis. All lesions except the intracerebral aspergillosis healed after combination antifungal treatment. Long-term voriconazole--but not posaconazole--therapy induced partial regression of the cerebral manifestations. At the time of writing, 3.5 years after the initial diagnosis, the patient is working half-time and suffers from a possible voriconazole-induced polyneuropathy.

Evaluation of pharmacy student empathy scores before and after a geriatrics advanced pharmacy practice experience (APPE).

INTRODUCTION: Empathy from healthcare providers is associated with improved patient care and satisfaction, resulting in increased emphasis on empathy in pharmacy school curricula. Previous studies showed improvement in pharmacy student empathy after older adult-specific simulation activities in the didactic setting, but no such data exist for the practice environment. This study's purpose was to evaluate the impact of a geriatrics advanced pharmacy practice experience (APPE) on pharmacy student empathy toward older adults. METHODS: All fourth-year pharmacy students in a geriatrics APPE at one of four participating sites were offered to participate in the study at the beginning of the rotation. Empathy was measured at baseline and end of the rotation using the Kiersma-Chen Empathy Scale (KCES). Wilcoxon matched-pairs signed-ranks test was used to test differences from pre- to post-rotation. RESULTS: Fifty-four of the 110 eligible students opted to participate in the study, and 46 completed both the pre- and post-surveys. Most students were female (55.6%), and the average age was 27.3 years. Mean empathy scores for all students increased significantly by 4.89 points (z = 4.17, P < .001, d = 0.97). Specific KCES items related to handling other's feelings and viewing another person's perspective also significantly improved. CONCLUSIONS: Empathy is a key component to professional development in healthcare students, and a geriatrics APPE provides an opportunity for students to grow this soft skill. Although further study is warranted, older adult focused rotations may be considered by schools of pharmacy to aid in preparing "graduate-ready" pharmacists.

Wolbachia Impacts Anaplasma Infection in Ixodes scapularis Tick Cells.

The specific interactions of members of tick bacterial microbiota and their effects on pathogen transmission remains relatively unexplored. Here, we introduced a novel Wolbachia infection type into Ixodes scapularis tick cells and examined the antipathogenic effects on the intracellular pathogen Anaplasma phagocytophilum. An increase in A. phagocytophilum replication was observed in Wolbachia-infected tick cells. However, Wolbachia infection densities decreased when cells were serially passaged and ultimately the infection was lost. Host-cell immune response was also examined as an additional factor that could have affected A. phagocytophilum replication in Wolbachia-infected cells. In early passages post-Wolbachia infection, a decreased immune response was observed, but in later passages of cells with low Wolbachia densities, there was no change in the immune response. The results are discussed in relation to the importance of studying the interactions of the tick microbiota, the host cell, and the pathogen and the development of novel tick and tick-borne disease-control approaches.

The Risk and Clinical Implications of Antibiotic-Associated Acute Kidney Injury: A Review of the Clinical Data for Agents with Signals from the Food and Drug Administration's Adverse Event Reporting System (FAERS) Database.

Antibiotic-associated acute kidney injury (AA-AKI) is quite common, especially among hospitalized patients; however, little is known about risk factors or mechanisms of why AA-AKI occurs. In this review, the authors have reviewed all available literature prior to 1 June 2022, with a large number of AKI reports. Information regarding risk factors of AA-AKI, mechanisms behind AA-AKI, and treatment/management principles to decrease AA-AKI risk were collected and reviewed. Patients treated in the inpatient setting are at increased risk of AA-AKI due to common risk factors: hypovolemia, concomitant use of other nephrotoxic medications, and exacerbation of comorbid conditions. Clinicians should attempt to correct risk factors for AA-AKI, choose antibiotic therapies with decreased association of AA-AKI to protect their high-risk patients, and narrow, when clinically possible, the use of antibiotics which have decreased incidence of AKI. To treat AKI, it is still recommended to discontinue all offending nephrotoxic agents and to renally adjust all medications according to package insert recommendations to decrease patient harm.

Oseltamivir-Induced Neuropsychiatric Event in an Older Person: A Case Report.

BACKGROUND: Oseltamivir is an effective agent for both the treatment and prevention of influenza, and its use is increasing. The package insert indicates that delirium and delirium-like events have been reported with the use of oseltamivir during postmarketing surveillance. The reports of neuropsychiatric events associated with oseltamivir are mainly in younger patients. To our knowledge, this is the first reported case of oseltamivirassociated neuropsychiatric events occurring with oseltamivir prophylaxis in an older adult.
CASE PRESENTATION: A 74-year-old male with a history of mild neurocognitive disorder was given oseltamivir prophylaxis in the setting of an influenza outbreak during his rehabilitation facility stay and developed newfound psychiatric symptoms after administration of oseltamivir for influenza prophylaxis because of institutional outbreak. The patient recovered completely after cessation of oseltamivir.
CONCLUSION: We hope that our case report highlights the importance of careful consideration when prescribing oseltamivir prophylaxis in older people with or without previous history of neurocognitive disorder.

PC Software for Artificial Intelligence Applications.

Our review has emphasized that AI tools are programming languages inspired by some problem-solving paradigm. We want to underscore their status as programming languages; even if an AI tool seems to fit a problem perfectly, its proficient use still requires the training and practice associated with any programming language. The programming manuals for PC-Plus, Smalltalk/ V, and Nexpert Object are all tutorial in nature, and the corresponding software packages come with sample applications. We find the manuals to be uniformly good introductions that try to anticipate the problems of a user who is new to the technology. All three vendors offer free technical support by telephone to licensed users. AI tools are sometimes oversold as a way to make programming easy or to avoid it altogether. The truth is that AI tools demand programming-but programming that allows you to concentrate on the essentials of the problem. If we had to implement a diagnostic system, we would look first to a product such as PC-Plus rather than BASIC or C, because PC-Plus is designed specifically for such a problem, whereas these conventional languages are not. If we had to implement a system that required graphical interfaces and could benefit from inheritance, we would look first to an object-oriented system such as Smalltalk/V that provides built-in mechanisms for both. If we had to implement an expert system that called for some mix of AI and conventional techniques, we would look first to a product such as Nexpert Object that integrates various problem-solving technologies. Finally, we might use FORTRAN if we were concerned primarily with programming a well-defined numerical algorithm. AI tools are a valuable complement to traditional languages.

Validity of routine surveillance data: a case study on Swedish notifications of methicillin-resistant Staphylococcus aureus.

Surveillance of communicable diseases is a public health corner stone. Routine notification data on communicable diseases are used as a basis for public health action as well as for policy making. While there are agreed standards for evaluating the performance of surveillance systems, it is rarely possible to analyse the validity of the data entered into these systems. In this study we compared data on all Swedish cases of methicillin-resistant Staphylococcus aureus (MRSA) routinely notified between 2000 and 2003 with follow-up information collected for each of these cases as part of a public health project. The variables Reason for testing (clinical sample, contact tracing, screening of risk group), Clinical presentation (disease, colonisation), Transmission setting (healthcare-acquired, community-acquired), Country of acquisition (Sweden, abroad) and Risk-occupation (yes, no) were analysed for sensitivity, positive predictive value and completeness of answers. The sensitivity varied between 23% and 83%, the positive predictive values were generally higher (55% to 97%), while missing answers varied from 11% to 59%. The proportion of community-acquired cases was markedly higher when excluding either cases of MRSA colonisation or cases found through public health-initiated activities (contact tracing or screening of risk groups). We conclude that the quality of routine surveillance data may be inadequate for in-depth epidemiological analyses. This should be taken into account when interpreting routine surveillance figures. Whether or not the case definition includes cases of MRSA colonisation may have a significant impact on population-wide estimates of MRSA occurrence.

Management of Extended-Spectrum Beta-Lactamase Urinary Tract Infections: Diagnostic and Treatment Considerations for the Older Adult.

OBJECTIVE: To review the treatment options for extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in the long-term care facility setting.
DATA SOURCES: A PubMed search from January 1, 1990, through December 31, 2018, using terms "extended spectrum beta lactamase" and "urinary tract infection" was performed. Current guidelines, drug databases, and manufacturer package inserts were also used.
STUDY SELECTION: All English-language articles during the above time frame appearing in these searches were reviewed for relevance to this paper. In addition, their bibliographies were reviewed to identify any articles not originally identified.
DATA SYNTHESIS: ESBL UTIs are a growing concern in the long-term care facility as these pathogens are becoming more prevalent. Patients residing in long-term care facilities have fewer treatment modalities because of medication administration and care issues. This review highlights the data on different antibiotics and their efficacy toward ESBLs in the setting of UTI.
CONCLUSIONS: Despite the challenges and limitations, there are still options for clinicians to provide optimal care, including antibiotics with different routes of administration, as well as different administration techniques. Clinicians can be successful with treating ESBL UTIs in older adults.

A review of citalopram dose restrictions in the treatment of neuropsychiatric disorders in older adults.

INTRODUCTION: Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful. METHODS: A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English. RESULTS: Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram. DISCUSSION: The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.

The gonadotropic function of insulin.

We have reviewed the role of insulin in ovarian physiology. Clinical observations and experimental data strongly support the hypothesis that insulin possesses gonadotropic activity, when acting alone or with FSH or LH. This idea is further supported by the recent discovery of insulin in follicular fluid. The idea that insulin has gonadotropic function can explain a variety of clinical observations, which otherwise are difficult to understand. For example, manifestations of ovarian hypofunction (primary amenorrhea, late menarche, anovulation, low pregnancy rate, and early menopause) in IDDM can be understood if it is accepted that insulin is necessary for the ovary to reach its full steroidogenic potential. The idea that insulin affects ovarian steroidogenesis also helps to understand the observation that hyperandrogenism frequently accompanies each of the various insulin-resistant states, regardless of the latter's etiology (e.g. genetic deficiency in the number of insulin receptors, antiinsulin receptor antibodies, obesity, etc.). The explanation for this association is based on the idea that hyperinsulinemia intensifies ovarian steroidogenesis, which manifests clinically as hyperandrogenism. Continuous stimulation of the ovary by insulin over a long period of time possibly produces morphological ovarian changes, such as hyperthecosis or polycystic changes; these changes commonly are observed among women with insulin resistance. The effects of insulin on ovarian cells are mediated possibly through binding of the peptide to its own receptor or to the IGF-1 receptor (the specificity spillover phenomenon). The latter could be an important mechanism in cases of insulin resistance. Potential mechanisms underlying the gonadotropic activity of insulin include direct effects on steroidogenic enzymes, modulation of FSH or LH receptor number, synergism with FSH or LH, or nonspecific enhancement of cell viability. The gonadotropic function of insulin adds yet another note to what has been termed a symphony of insulin action. Further investigation into this new area may yield greater insights not only into normal ovarian physiology, but also into the pathogeneses of such diverse entities as PCO, obesity, diabetes mellitus, and the syndromes of insulin resistance and acanthosis nigricans.