Patients with high tacrolimus clearance eliminate more drug within a dose interval compared with those with low clearance. Delays in dosing time will result in transient periods of lower ...concentrations in high versus low clearance patients. Transient subtherapeutic tacrolimus concentrations may induce acute rejection episodes.
A retrospective study in all renal transplant patients treated with tacrolimus at our center from 2009 to 2013 was conducted. The association between individually estimated tacrolimus clearance (daily tacrolimus dose mg/trough concentration μg/L) and biopsy-proven acute rejection (BPAR) the first 90 days posttransplantation was investigated.
In total, 638 patients treated with oral tacrolimus were included in the analysis. Eighty-five (13.3%) patients experienced BPAR. Patients were stratified into 4 groups per their estimated clearance. The patients in the high clearance group had significantly higher incidence of BPAR (20.6%) with a hazard ratio of 2.39 (95% confidence interval, 1.30-4.40) compared with the low clearance group. Clearance estimate (as a continuous variable) showed a hazard ratio of 2.25 (95% confidence interval, 1.70-2.99) after adjusting for other risk factors. There were no significant differences in neither trough concentrations the first week after transplantation nor time to target trough concentration between patients later experiencing BPAR or not.
High estimated clearance is significantly associated with increased risk of BPAR the first 90 days posttransplantation and may predict an increased risk of rejection in the early phase after renal transplantation.
Purpose
The aim of the present study was to investigate the effect of age on venlafaxine and escitalopram serum concentrations in various
cytochrome P450 (CYP) 2D6
and
CYP2C19
genotype subgroups.
...Methods
Serum concentration measurements from
CYP-
genotyped patients treated with venlafaxine (
n
= 255) or escitalopram (
n
= 541) were collected retrospectively from a therapeutic drug monitoring database. Patients were divided into three CYP2D6 (venlafaxine) or CYP2C19 (escitalopram) phenotype subgroups according to inherited genotype, i.e., poor metabolizers (PMs), heterozygous extensive metabolizers (HEMs), and extensive metabolizers (EMs), and subsequently distributed into three age groups, i.e., <40 (control), 40–65, and >65 years. The effect of age on dose-adjusted serum concentrations (i.e., nmol/L/mg/day) of venlafaxine and escitalopram in each of the phenotype subgroups was evaluated by separate multivariate mixed model analyses.
Results
In CYP2D6 PMs, the mean dose-adjusted serum concentration of venlafaxine was 8-fold higher in patients >65 years compared with those <40 years (
p
< 0.001). In comparison, the respective age-related differences in mean dose-adjusted serum concentrations of venlafaxine were much less pronounced in CYP2D6 HEMs and EMs (<2-fold differences between age groups). A similar genotype-related effect of age was not observed for escitalopram (<1.5-fold age differences in all CYP2C19 subgroups).
Conclusion
This study suggests that the effect of age on serum concentration of venlafaxine is dependent on
CYP
genotype, in contrast to escitalopram. Thus, to prevent potential side effects, it might be particularly relevant to consider
CYP2D6
genotyping prior to initiation of venlafaxine treatment in older patients.
The aim of the present study was to conduct a systematic review of head and neck Ewing sarcoma (ES) concerning patients' demographic and clinical features, histopathological findings, treatment, ...follow-up, and survival rate.
An electronic search was undertaken in four databases. Articles describing case reports or case series were included. Outcomes were evaluated by the Kaplan-Meier method along with Cox regression.
The search yielded 186 studies describing 227 ES cases. The mean age was 22.7 years, and males were slightly more affected. Interestingly, more than half the cases were diagnosed up to 20 years. The respiratory tract was the most reported site, followed by the jawbones. Clinically, symptomatic swelling or nodules were described, with a mean duration of 4 months. Management involved multimodal treatment regimens. Local recurrence, lymph node and distant metastasis were observed in 10.7%, 12.6%, and 20.3% of cases, respectively. Statistical analysis revealed that older patients with distant metastasis had a lower overall survival rate (p < 0.05).
This study provides an overall view of head and neck ES that can assist oral and maxillofacial pathologists with the diagnosis and extend the knowledge of surgeons and oncologists about this condition.
Hypoglycaemia is associated with cognitive and functional decline in older people with diabetes. Identification of individuals at risk and prevention of hypoglycaemia is therefore an important task ...in the management of diabetes in older home-dwelling individuals. The purpose of this scoping review was to map the literature on hypoglycaemia in home-dwelling older people with diabetes.
This scoping review included original research articles on hypoglycaemia in older (≥ 65 years) individuals with diabetes from developed countries. A broad search of the databases Cinahl, Embase and Medline was performed in July 2018. The report of the scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews.
Our database search identified 577 articles of which 23 were eligible for inclusion. The identified literature was within four areas: 1) incidence of hypoglycaemia in older home-dwelling people with diabetes (11/23 articles), 2) risk factors of hypoglycaemia (9/23), 3) diabetes knowledge and self-management (6/23) and 4) consequences of hypoglycaemia for health care use (6/23). The majority of the literature focused on severe hypoglycaemia and the emergency situation. The literature on diabetes knowledge and management related to preventing adverse events relevant to older home-dwellers, was limited. We found no literature on long-term consequences of hypoglycaemia for the use of home health care services and the older persons' ability to remain home-dwelling.
We identified a lack of studies on prevention and management of hypoglycaemia in the older individuals' homes. Such knowledge is of utmost importance in the current situation where most western countries' governmental policies aim to treat and manage complex health conditions in the patient's home. Future studies addressing hypoglycaemia in older individuals with diabetes are needed in order to tailor interventions aiming to enable them to remain home-dwelling as long as possible.
Diabetes-related foot ulcers (DFU) are a persistent healthcare challenge, impacting both patients and healthcare systems, with adverse effects on quality of life and productivity. Our primary aim was ...to examine the trends in lifetime prevalence of DFU, as well as other micro- and macrovascular complications in the Trøndelag Health Study (HUNT) in Norway.
This study consists of individuals ≥20 years with diabetes participating in the population-based cross-sectional HUNT surveys (1995-2019). Prevalence ratios, comparing the lifetime prevalence of DFU and other relevant micro- and macrovascular complications between the HUNT surveys, were calculated using Poisson regression.
The lifetime prevalence (95% confidence interval (CI)) of a DFU requiring three or more weeks to heal was 11.0% (9.5-12.7) in HUNT2, 7.5% (6.3-8.8) in HUNT3 and 5.3% (4.4-6.3) in HUNT4. The decrease in DFU prevalence from 1995 to 2019 was observed in both men and women, for all age groups, and for both type 1 and type 2 diabetes. The highest lifetime prevalence of DFU was found among those with type 1 diabetes. The decrease in HbA1c from HUNT2 to HUNT4 did not differ between those with and without a DFU. The prevalence of chronic kidney disease (eGFR <60 mL/min/1.73 m
(eGFR categories G3-G5)) increased in both individuals with and without a DFU.
Results from the HUNT surveys show a substantial decline in the lifetime prevalence of DFU from 1995 to 2019.
Abstract
Background
A scoping review from 2021 identified a lack of studies on the incidence, prevention and management of hypoglycaemia in home-dwelling older people with diabetes. The aim of this ...study was to investigate the frequency and duration of hypoglycaemic episodes measured by continuous glucose monitoring (CGM) in older people with diabetes who received home care and who were treated with glucose-lowering medications, and to compare the frequency and duration of hypoglycaemic episodes between subgroups of the study population according to demographic and clinical variables.
Methods
This was an observational study investigating the occurrence of hypoglycaemia in people with diabetes aged ≥ 65 years. Data were collected using blinded continuous glucose monitoring (CGM, iPro2) for 5 consecutive days. Frequency and duration of hypoglycaemic episodes were assessed using a sensor glucose cut-off value of 3.9 mmol/L. A blood sample for measurement of HbA1c and creatinine-based eGFR (CKD-EPI) was obtained during the monitoring period. Demographic and clinical data were collected from electronic patient records.
Results
Fifty-six individuals were enrolled (median age 82 years and 52% were men). Of the 36 participants who were treated with insulin, 33% had at least one hypoglycaemic episode during the five-day period. Among 18 participants who neither used insulin nor sulfonylurea, but other glucose-lowering medications, 44% had at least one hypoglycaemicepisode. Of those with hypoglycaemic episodes, 86% lived alone. The median duration of the hypoglycaemia was 1 h and 25 min, ranging from 15 min to 8 h and 50 min.
Conclusion
This study identified an unacceptably high number of unknown hypoglycaemic episodes among older home-dwelling people with diabetes receiving home care, even among those not using insulin or sulfonylurea. The study provides essential knowledge that can serve as a foundation to improve the treatment and care for this vulnerable patient group. The routines for glucose monitoring and other prevention tasks need to be considered more comprehensively, also, among those treated with glucose-lowering medications other than insulin.
Hypoglycemic incidents in older people can cause severe health problems, enhance general age-related disabilities, and cause frailty. Little is known about incidences of hypoglycemia in older ...home-dwelling people with diabetes. Thus, the aim of this study was to examine the feasibility of capturing hypoglycemia and issues associated with increased risk of hypoglycemia by use of continuous glucose monitoring (CGM) and standardized questionnaires among older home-dwelling individuals with diabetes type 2 receiving home care.
CGM with the Ipro2-blinded monitoring system were performed for 5 days in six home-dwelling individuals ≥ 75 years diagnosed with diabetes and receiving home care. Demographic (age, gender, living arrangements) and clinical data (diabetes diagnoses and duration, diabetes medication, documented treatment goal, available glycosylated hemoglobin (HbA1c)) were collected from electronic patient records in home care services. Feasibility (ease of use, quality of data, time spent) of standardized questionnaires to identify the risk of hypoglycemia (the McKellar Risk Assessment Tool), risk of malnutrition (the Mini Nutritional Assessment (MNA)), functional status (the Individual-based Statistics for Nursing and Care Services (IPLOS)), and cognitive status (the Mini Mental Status Exam (MMSE)) was also assessed. Questionnaire data was collected by a study nurse in the individuals' home.
The practical use of CGM was satisfactory, with no major remarks about discomfort or technical errors, except for one participant with skin reaction (redness). Collecting data with the McKellar Risk Assessment Tool, MNA and IPLOS worked well according to quality of data, time spent, and ease of use. The MMSE survey required extensive training of personnel to be conducted.
The feasibility study informs an upcoming study on the incidence and risk factors of hypoglycemia in home-dwelling older individuals. We will ascertain that personnel who will use the MMSE questionnaire to collect cognitive status and skills are familiar with the tool and adequately educated and trained before study start. The use of blinded CGM in this population was well tolerated and can be used "as is" for future studies.
Home care services plays an important role in diabetes management, and to enable older adults remain home-dwellers. Adequate follow-up and systematic nursing documentation are necessary elements in ...high quality diabetes care. Therefore, the purpose of this study was to examine the diabetes treatment and management for older persons with diabetes receiving home care services.
A cross-sectional study was used to assess the diabetes treatment and management in a Norwegian municipality. Demographic (age, sex, living situation) and clinical data (diabetes diagnose, type of glucose lowering treatment, diabetes-related comorbidities, functional status) were collected from electronic home care records. Also, information on diabetes management; i.e. follow-up routines on glycated haemoglobin (HbA
), self-monitoring of blood glucose, insulin administration and risk factors (blood pressure, body mass index and nutritional status) were registered. HbA
was measured upon inclusion. Descriptive and inferential statistics were applied in the data analysis.
A total of 92 home care records from older home-dwelling persons with diabetes, aged 66-99 years were assessed. Only 52 (57 %) of the individuals had the diabetes diagnosis documented in the home care record. A routine for self-monitoring of blood glucose was documented for 27 (29 %) of the individuals. Only 2 (2 %) had individual target for HbA
documented and only 3 (3 %) had a documented routine for measuring HbA
as recommended in international guidelines. Among 30 insulin treated older individuals, a description of the insulin regimen lacked in 4 (13 %) of the home care records. Also, documentation on who performed self-monitoring of blood glucose was unclear or lacking for 5 (17 %) individuals.
The study demonstrates lack of documentation in home care records with respect to diagnosis, treatment goals and routines for monitoring of blood glucose, as well as insufficient documentation on responsibilities of diabetes management among older home-dwelling adults living with diabetes. This indicates that home care services may be suboptimal and a potential threat to patient safety.
Risks associated with polypharmacy and drug-drug interactions represent a challenge in drug treatment, especially in older adults. The aim of the present study was to assess the use of prescription ...and non-prescription drugs and the frequency of potential drug-drug interactions in home-dwelling older individuals.
A cross-sectional study design was applied. Data were collected during preventive home visits among individuals aged ≥75 in three separate communities of Western Norway. A questionnaire, which was filled out by the individual, their next-of-kin, and the nurse performing the home visit was used for the collection of demographic and clinical data (age, sex, medication use, diagnoses, need of assistance with drug administration). Potential drug-drug interactions were identified electronically by IBM Micromedex Drug Interaction Checking. Point prevalence of potential drug-drug interactions and polypharmacy (≥5 drugs) were calculated. Binary logistic regression analyses were performed to assess factors potentially associated with polypharmacy or potential drug-drug interactions.
Among the 233 individuals (mean age 78±3 years, 46% male) included in the study, 43% used ≥5 drugs, 3.4% ≥10 drugs, while 4.3% used no drugs. In 54% of the 197 individuals using two or more drugs, at least one potential drug-drug interaction was detected. Low-dose aspirin and simvastatin were most frequently involved in potential drug-drug interactions. In total, 25% of the individuals reported current use of drugs sold over the counter of which more than 95% were analgesic drugs. Potential drug-drug interactions involving ibuprofen were identified in nine of 11 (82%) individuals using over-the-counter ibuprofen.
The study revealed a high prevalence of polypharmacy and potential drug-drug interactions with both prescription and non-prescription drugs in older home-dwelling individuals. Close monitoring of the patients at risk of drug-drug interactions, and increased awareness of the potential of over-the-counter drugs to cause drug-drug interactions, is needed.
Assessing self-rated health by preventive home visits of older people can provide information about the person's well-being, quality of life and risk of developing illness. The aim of this study was ...to examine associations between self-rated health and factors related to demographics, lifestyle, health conditions and medical diagnoses by older people participating in a preventive home visit program.
A cross-sectional study including 233 participants (age 75-79) from three municipalities of Western Norway was conducted. Data were collected through preventive home visits performed by six nurses, using a questionnaire including self-rated health assessment and questions and tests related to demographics (e.g. education and housing), lifestyle (e.g. social activities, alcohol and smoking), health conditions (e.g. sensory impairment, pain and limited by disease) and medical diagnoses. Descriptive and inferential statistics including linear block-wise regression model were applied.
The block-wise regression model showed that the variables Limited by disease and Pain were negatively associated with self-rated health and Use internet was positively associated. The model had a R
0.432. The variable that contributed to largest change in the model was Limited by disease (R
Change; 0.297, p-value< 0.001).
In the present study, being limited by disease and pain were strongly associated with poor self-rated health, indicating that these are important factors to assess during a preventive home visit. Also, digital competence (Use internet) was associated with a better self-rated health, suggesting that it could be useful to ask, inform and motivate for the use of digital tools that may compensate for or improve social support, social contact and access to health -related information.
PDF
