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Abstract Background Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels). Methods A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded. Results Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, β2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16). Conclusion Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.

Abstract Concurrent hemolysis in patients with vitamin B12 deficiency is a well-recognized phenomenon and has been attributed to intramedullary destruction of erythrocytes (ineffective erythropoiesis). Recent studies revealed that homocysteine increased the risk of hemolysis in vitamin B12 deficiency in vitro and there is a high frequency (30%) of vitamin B12 deficiency in asymptomatic patients with homozygous methylene tetrahydrofolate reductase (MTHFR) C677T mutation, a known cause of hyperhomocysteinemia. Here we report three patients with MTHFR mutations and vitamin B12 deficiency presenting with hemolytic anemia and severely elevated homocysteine levels. Patients demonstrated complete resolution of hemolysis with simultaneous normalization of serum homocysteine levels after vitamin B12 treatments. We reviewed pertinent literature, and hypothesized that hemolytic anemia may be more prevalent in patients who have a coexisting MTHFR gene mutation and vitamin B12 deficiency possibly related to severely elevated homocysteine levels. The hemolysis in these cases occurred predominantly in peripheral blood likely due to the combined effects of structurally defective erythrocytes and homocysteine-induced endothelial damage with microangiopathy.

Context: Subclinical features of zinc deficiency can be challenging to recognize. The prevalence of zinc deficiency based on blood zinc concentration in an adult outpatient clinic setting has not been well-studied., Objective: To estimate the prevalence of low serum zinc concentrations among community-dwelling adults, and to characterize clinical features and risk factors associated with zinc deficiency., Methods: This retrospective pilot prevalence study took place from 2014 to 2017 at an outpatient clinic in southeast Ohio. Patients aged 50 years or older with a stable health status were categorized into a case group with zinc deficiency (serum zinc concentration, <0.66 µg/mL) and a control group (serum zinc concentration, ≥0.66 µg/mL). Measurements included serum zinc concentration, nutritional biomarkers (ie, magnesium, calcium, albumin, and total 25-hydroxy vitamin D levels), patient history of fractures and events such as hospitalization, antibiotic use, and self-reported falls that occurred within 1 year prior to the date serum zinc concentration was measured (index date). Patients were excluded if they had a serum zinc measurement within 2 months after a hospitalization, severe renal insufficiency (3 patients with serum creatinine concentration above 2.5 mg/dL), or serum zinc concentration above 1.20 µg/mL., Results: This study included 157 patients, consisting of a case group of 41 (26%) patients with zinc deficiency and a control group of 116 (74%) without zinc deficiency. Mean (SD) zinc concentrations of the case and control groups were 0.58 (0.05) µg/mL and 0.803 (0.13) µg/mL, respectively (P<.01). Patients in the case group were more likely to have had a history of hospitalization, antibiotic use, a fall within 1 year before the index date, and a history of fractures and hip fracture (P<.01 in each case). Patients taking gastric acid suppressants had increased odds of lower zinc concentrations (odds ratio, 2.24; 95% CI, 1.08-4.63). Both logistic and multivariate linear regression models revealed that past fractures, hip fractures, and hypoalbuminemia (albumin <3.5 g/dL) were associated with zinc deficiency or lower zinc concentrations., Conclusion: This study revealed that 26% of patients in an outpatient adult clinic had zinc deficiency based on serum concentrations. Patients with fracture history and low serum albumin were at higher risk for zinc deficiency.

Pyoderma gangrenosum (PG) is a rare but serious neutrophilic dermatosis characterized by ulcerative lesions with violaceous borders. The disease mainly occurs in young or middle-aged adults. The authors present the case of a 79-year-old female nursing home patient who had an idiopathic PG-like ulcer on her lower extremity. Initial treatment with 3 courses of antibiotics and topical wound care for assumed cellulitis failed to improve the lesion, but the ulcer healed rapidly after a 1-week course of prednisone therapy (15 mg/d). This case provides insights into the challenges that arise in the diagnosis and management of PG in an older patient with extensive comorbidities. It also highlights the importance of considering PG as a diagnosis for older patients with a distinctive inflammatory ulcer that does not respond to antibiotics and topical wound care, since timely treatment with low-dose steroids can lead to quick healing by aborting the underlying autoinflammatory process.

Objective: To investigate the possibility of using Ryodoraku as a tool to indicate sympathetic neuronal activity., Methods: Twenty-two female college students were assigned to an treadmill exercise program (three times a week for six weeks), and another 25 were assigned as controls. Skin conductance levels of the subjects were measured at 24 Ryodoraku points on the wrists and the ankles, along with heart rate variability (HRV) analysis, during and after the treadmill exercise period., Results: The six-week exercise training resulted in a significant elevation of the average electrical conductance, which returned to the pre-training level after three months of cessation of the exercise training., Conclusion: HRV data have shown no similar changes, suggesting that Ryodoraku is a useful tool in detecting subtle, non-cardiovascular physical responses.

Context: Although bacteriuria with acute coexisting illness is common in hospitalized older adults, distinguishing it from urinary tract infection (UTI) can be challenging., Objectives: To examine the rate of agreement between two geriatricians in distinguishing UTI from asymptomatic bacteriuria (ASB). To analyze the incidence of associated acute comorbidities and determine if an association exists between clinical manifestations and bacteriuria status on acute hospital admission., Methods: Two physicians conducted a retrospective analysis of 296 inpatient records, including 142 records from age- and condition-matched nonbacteriuria control subjects. Using consensus criteria to diagnose UTI vs ASB, these independent experts evaluated inpatient records, including admission and discharge diagnoses as well as urinalysis results. A kappa statistic was used to determine reviewer agreement. Risk assessment was measured by odds ratio with a 95% confidence interval., Results: Expert agreement for the diagnosis of UTI and ASB was 98% and 44%, respectively. Agreement was reached at a level greater than chance (z=6.74, P<.001, kappa=0.49). In the 30 cases where interexpert agreement was not reached, half of the subjects had acute pulmonary disease. Symptom crossover for this comorbid condition is the likely cause for lack of diagnostic agreement. Among other conditions observed, delirium was most common in UTI subjects., Conclusion: Limited interexpert agreement seemed to result from difficulty in diagnosing patients who had no local symptoms but acute comorbid conditions with potential symptom crossover. Among the conditions observed in our sample population, delirium was most closely associated with UTI.

We examined presynaptic cholinergic markers and beta-secretase activity during progressive central nervous system amyloidogenesis in Tg2576 Alzheimer mice (transgenic for human amyloid precursor protein Swedish mutation; hAPPswe). At 14, 18, and 23 months of age there were no significant differences between wild-type and transgenic mice in four distinct central nervous system cholinergic indices--choline acetyltransferase and acetylcholinesterase activities, and binding to vesicular acetylcholine transporter and Na(+)-dependent high-affinity choline uptake sites. A novel enzyme-linked immunosorbent assay measuring only the secreted human beta-secretase cleavage product (APPsbetaswe) of APPswe also revealed no change with aging in Tg2576 mouse brain. In contrast, transgenic but not wild-type mice exhibited an age-dependent increase in soluble Abeta40 and Abeta42 levels and progressive amyloid deposition in brain. Thus, aging Tg2576 mice exhibited presynaptic cholinergic integrity despite progressively increased soluble Abeta40 and Abeta42 levels and amyloid plaque density in brain. Older Tg2576 mice may best resemble preclinical or early stages of human Alzheimer's disease with preserved presynaptic cholinergic innervation. Homeostatic APPsbetaswe levels with aging suggest that progressive amyloid deposition in brain results not from increased beta-secretase cleavage of APP but from impaired Abeta/amyloid clearance mechanisms.