The low dopamine hypothesis: A plausible mechanism underpinning residual urine, overactive bladder and nocturia (RON) syndrome in older patients

INTRODUCTION

Aging is associated with a combination of several lower urinary tract (LUT) signs and symptoms, including residual urine, overactive bladder and nocturia. One of the mechanisms of this LUT dysfunction that has not been discussed in dept so far is the role of dopamine (DA).

METHODS

In this narrative review, we explore the dopaminergic hypothesis in the development of this combination of LUT signs and symptoms in older adults.

RESULTS

DA is one of the neurotransmitters whose regulation and production is disrupted in aging. In synucleinopathies, altered DAergic activity is associated with the occurrence of LUTS and sleep disorders. Projections of DAergic neurons are involved in the regulation of sleep, diuresis, and bladder activity. The low dopamine hypothesis could explain the genesis of a set of LUT signs and symptoms commonly seen in this population, including elevated residual urine, Overactive bladder syndrome and Nocturia (discussed as the RON syndrome). This presentation is however also common in older patients without synucleinopathies or neurological disorders and therefore we hypothesise that altered DAergic activity because of pathological aging, and selective destruction of DAergic neurons, could underpin the presentation of this triad of LUT dysfunction in the older population.

CONCLUSION

The concept of RON syndrome helps to better understand this common phenotypic presentation in clinical practice, and therefore serves as a useful platform to diagnose and treat LUTS in older adults. Besides recognizing the synucleinopathy "red flag" symptoms, this set of multi-causal LUT signs and symptoms highlights the inevitable need for combination therapy, a challenge in older people with their comorbidities and concomitant medications.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Potentially inappropriate prescribing and its demographic and clinical correlates in older adults with atrial fibrillation: a population-based study

Introduction

Older adults with atrial fibrillation (AF) have an increased risk of comorbidities and often take a combination of medicines. Moreover, it is known that anticoagulants tend to be underprescribed or underdosed in older patients with AF. Thus, it is important to evaluate the overall quality of prescribing because potentially inappropriate prescribing is associated with serious adverse events.

Purpose

To assess the quality of prescribing and to analyze the association between potentially inappropriate prescribing with demographic and clinical variables in a Swedish urban older population with AF.

Methodology

The Swedish National Study on Aging and Care is an observational longitudinal population-based study (baseline: 2001–2004) of adults aged 60 years or older (n=3363). We used the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) version 2 algorithms (1) to assess the quality of prescribing. STOPP and START criteria identify potentially inappropriately prescribed medications and medications that are omitted but should have been prescribed, respectively. We could apply 72% of the STOPP criteria and 50% of the START criteria to the dataset. A hurdle negative binomial regression model was fitted to investigate the association between STOPP/START and age, sex, polypharmacy, and functional status indicated by activities of daily living.

Results

We analyzed data on 293 participants with AF. STOPP and START criteria occurred in 53.6% and 63.5% of older patients with AF, respectively. The most frequently inappropriately prescribed drugs (STOPP) were anticoagulants (4.8%), hypnotic Z-drugs (19.1%), benzodiazepines (19.1%) and drugs contributing to anticholinergic burden (6.8%). The most frequently omitted drugs (START) were antiplatelets (26%), anticoagulants (26%), statins (14.3%), beta-blockers (17.7%), vitamin D (15.7%), calcium supplements (15.7%) and laxatives (16%).

Polypharmacy (≥5 drugs; OR 3.45; 95% CI 1.85–6.44) was significantly associated with higher odds of having at least one STOPP criterion (Table 1). Disability (OR 2.56; 95% CI 1.26–5.21) was significantly associated with higher odds of having at least one START criterion.

Among persons with at least one STOPP or START criterion, the estimated mean number of STOPP and START criterion were 2.35 (95% CI 1.36–4.09) and 2.49 (95% CI 1.48–4.21) times higher, respectively, in persons with high polypharmacy (>10 drugs) compared to those without polypharmacy.

Conclusion

Potentially inappropriate prescribing and prescribing omissions were prevalent in this population of older adults with AF, beyond the well-known case of anticoagulants. Thorough multi-disciplinary medication reviews might improve quality of prescribing, especially in those with polypharmacy and functional impairment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 899871.

The comorbidity network in older adults with atrial fibrillation: a Danish nationwide cohort study

Introduction

Individuals affected by atrial fibrillation (AF) often present with multiple comorbidities that challenge their clinical management and worsen the prognosis. Characterizing the network structure of comorbid chronic conditions in AF patients may provide insights to better tailor medical and care management.

Purpose

To examine and compare the network structure of comorbidities in older people with and without AF.

Methods

Cross-sectional data derived from the Danish National Patient Register (period 2012–2017) were examined. Patients 60+ years old by 1. January 2017 with AF were selected and matched by age and sex to non-AF controls. Chronic conditions coded according to the International Classification of Diseases, 10th revision were retrieved and grouped into 60 clinically relevant disease categories for old age. Network analysis was applied to construct the disease networks and the centrality index of expected influence was measured to estimate the disease interconnectedness in each network. The difference in network structure and disease centrality between AF and non-AF patients was formally assessed through network comparison tests.

Results

A total of 96,117 AF patients (72 years old; 45% women) were identified and matched with 96,117 non-AF controls. The most prevalent chronic conditions in AF were hypertension (55.1%), large bowel diseases (36.4%) and ischemic heart disease (36.0%). A significant difference of global network structure was observed between AF and non-AF patients (p<0.001) (Figure1). Chronic obstructive pulmonary disease, depression, inflammatory arthropathy, chronic kidney disease and peripheral neuropathy had a higher connectivity with other diseases in the AF vs. non-AF patients (p<0.001). By contrast, hypertension, heart failure and stroke were more interconnected in the non-AF patients (p<0.001). Among AF patients, network differences were further observed between age categories (60–79 vs 80+ years) in male and female subgroups.

Conclusions

Older AF patients exhibited a complex network structure of chronic conditions that differed from age- and sex- matched non-AF patients. The network-based identification of highly co-morbid diseases in AF can improve our understanding of AF-related chronic conditions and potentially enhance prioritization and a personalized care for older patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Surface modification of poly(methyl-methacrylate) with farnesol to prevent Candida biofilm formation

Candida albicans promotes biofilm formation on dentures, which compromises the use of poly(methyl-methacrylate) (PMMA) as a dental material. Farnesol (FAR), a natural compound that prevents C. albicans filamentation and biofilm formation, was incorporated into the PMMA matrix, to obtain antifungal PMMA_FAR materials. The tested concentrations (0·0125% and 0·4%) of FAR, 24 h after incubation on YPD agar, inhibited filamentation of C. albicans. PMMA was modified with different FAR concentrations (3-12%), and physicochemical properties, antifungal activity and cytotoxicity of these modified materials (PMMA_FAR) were tested. The presence of FAR in PMMA_FAR composites was verified by Fourier-transform infrared spectroscopy (FT-IR). Incorporation of FAR into the polymeric matrix significantly decreased hydrophilicity at all tested concentrations and significantly reduced biofilm and planktonic cells metabolic activity in the early stage of biofilm formation at ≥6% FAR in PMMA. PMMA_FAR composites with <9% FAR were non-toxic. Modification of PMMA with FAR is a good strategy for reducing C. albicans biofilm formation on dentures.

Obesity and decreased vibration perception associated with premature cardiovascular mortality in a single center prospective study of people with diabetes

Background and aims

The aim of this prospective, single center study was to define factors associated with early cardiovascular mortality in diabetes.

Materials and methods

1345 patients under age 75 were included who were undergoing assessment of their diabetes between January 2008 and May 2010 as part of standard practice in a specialist clinic at a regional teaching hospital in Serbia. Peripheral artery disease (PAD) was assessed by audible Doppler waveform and ABPI with cut-offs &gt;1.4 and &lt;0.9. Peripheral neuropathy was assessed by vibration perception threshold (VPT, using a semi-quantitative tuning fork: abnormal if ≤5), ankle reflexes (AR) and sudomotor function of the foot. Diabetic retinopathy (DR) was assessed by fundoscopy. Evidence of vascular disease: thromboendarterectomy and/or cerebrovascular insult (TEA/CVI), myocardial infarction (MI), heart failure (HF), diabetic foot ulcer (DFU), minor amputations (sAMP) and major amputations (mAMP) was also collected. Outcome was determined in 2021 and baseline characteristics were compared between those who had and had not suffered cardiovascular death under age 75 years within 10 years of review in two casually selected cohorts.

Results

Those who died (n2=70) were more frequently male (60 vs. 45.3%, p=0.08), younger (66.4±7.4 vs. 79.9±3.4, p&lt;0.000), had a shorter period of follow-up (3.6±2.3 vs. 11.2±1.7 years, p&lt;0.000) when compared to those still alive (n1=75). Those who died were also significantly (p&lt;0.01) more likely to have had TEA/CVI (34.3 vs. 10.7%), HF (21.4 vs. 1.3%), MI (44.3 vs. 20%), PAD (48.6 vs. 9.3%), DFU (25.7 vs. 9.3%), mAMP (17.1 vs. 1.3%) at baseline. There were no differences in proliferative DR (17.1 vs. 8%, p=0.10) and laser photocoagulation (25.7 vs. 13.3%, p=0.06) Following multivariable logistic regression analysis significant differences between groups remained for only creatinine (123±45 vs. 88.9±16.9 mmol/L, p&lt;0.003) and VPT &lt;5 (7.8 [95% CI: 3.7–16.4)], p=0.008), estimated maximum lifetime BMI (3.4 [95% CI: 1.7–6.8)], p&lt;0.000), alcohol usage (4.7 [95% CI: 1.5–14.7)], p=0.005), smoking habit (2.2 [95% CI: 1.1–4.3)], p&lt;0.03) and earlier age of diabetes onset (43.4±12.5 vs. 49.2±9.9, p=0.0029). When the 72 patients with impaired vibration sense were compared with 73 with VPT&gt;6, there were significant differences in TEA/CVI (4.2 [95% CI: 1.6–10.9)], p=0.003), PAD (3.9 [95% CI: 1.8–8.8)], p&lt;0.001) and estimated maximum lifetime BMI (9.4 [95% CI: 3.4–25.7), p&lt;0.000). Finally, when those who had had a previous MI at baseline (n=46) were compared with those who hadn't (n=99), MI was associated with increased death rate (3.2 [95% CI: 1.5–6.6)], p=0.002), as was PAD (2.9 [(1.3–6.1)], p=0.007).

Conclusion

Decreased VPT, the presence of PAD on clinical testing and higher maximum estimated lifetime BMI are strongly associated with premature cardiovascular death. These measures may be independent markers of greater risk of reduced life expectancy.

Funding Acknowledgement

Type of funding sources: None.

Assessing the occurrence of pharmaceuticals and antibiotic resistance genes during the anaerobic treatment of slaughterhouse wastewater at different temperatures

This study investigates the effect of psychrophilic, mesophilic and thermophilic temperatures on the anaerobic treatment of slaughterhouse wastewater, in terms of biogas production, occurrence of 30 pharmaceutical compounds of veterinary use, 4 antibiotic resistance genes (ARGs) which provide resistance to tetracyclines (tetW), fluoroquinolones (qnrS), macrolide-lincosamide-streptogramin (ermB) and sulfonamides (sul1) antibiotics, as well as class I integron-integrase gene (intI1), related to horizontal gene transfer. The highest methane yield was obtained at a mesophilic temperature (35 °C) (323 mL CH₄/g TCOD) followed by the yield obtained at thermophilic temperature (53 °C) (242 mL CH₄/g TCOD). Regarding pharmaceuticals, chlortetracycline, oxytetracycline, tilmicosin, and lincomycin were the most abundant in the slaughterhouse wastewater, being detected predominantly in the solid phase (with median concentrations >200 μg/kg dry weight). On the other hand, ciprofloxacin, ofloxacin, norfloxacin, lincomycin and ibuprofen were the most predominant in the anaerobic digestate regardless of the treatment temperature. Psychrophilic temperatures (21 °C) exhibited moderate to low pharmaceuticals removal, while a large fraction of them were removed at a thermophilic temperature reaching 70-90% removals for tetracycline, macrolides and one sulfonamide (sulfapyridine). The highest relative abundance of the quantified ARGs was found at 53 °C, suggesting that thermophilic temperatures normally associated with better removals of pathogens do not necessarily show better removals of antibiotic resistance genes.

Management actions to mitigate the occurrence of pharmaceuticals in river networks in a global change context

Human consumption of pharmaceuticals leads to high concentrations of pharmaceuticals in wastewater, which is usually not or insufficiently collected and treated before release into freshwater ecosystems. There, pharmaceuticals may pose a threat to aquatic biota. Unfortunately, occurrence data of pharmaceuticals in freshwaters at the global scale is scarce and unevenly distributed, thus preventing the identification of hotspots, the prediction of the impact of Global Change (particularly streamflow and population changes) on their occurrence, and the design of appropriate mitigation actions. Here, we use diclofenac (DCL) as a typical pharmaceutical contaminant, and a global model of DCL chemical fate based on wastewater sanitation, population density and hydrology to estimate current concentrations in the river network, the impact of future changes in runoff and population, and potential mitigation actions in line with the Sustainable Development Goals. Our model is calibrated against measurements available in the literature. We estimate that 2.74 ± 0.63% of global river network length has DCL concentrations exceeding the proposed EU Watch list limit (100 ng L^-1). Furthermore, many rivers downstream from highly populated areas show values beyond 1000 ng L^-1, particularly those associated to megacities in Asia lacking sufficient wastewater treatment. This situation will worsen with Global Change, as streamflow changes and human population growth will increase the proportion of the river network above 100 ng L^-1 up to 3.10 ± 0.72%. Given this background, we assessed feasible source and end-of-pipe mitigation actions, including per capita consumption reduction through eco-directed sustainable prescribing (EDSP), the implementation of the United Nations Sustainable Development Goal (SDG) 6 of halving the proportion of population without access to safely managed sanitation services, and improvement of wastewater treatment plants up to the Swiss standards. Among the considered end-of-pipe mitigation actions, implementation of SDG 6 was the most effective, reducing the proportion of the river network above 100 ng L^-1 down to 2.95 ± 0.68%. However, EDSP brought this proportion down to 2.80 ± 0.64%. Overall, our findings indicate that the sole implementation of technological improvements will be insufficient to prevent the expected increase in pharmaceuticals concentration, and that technological solution need to be combined with source mitigation actions.

[Towards proactive and personalised care for the elderly]

The Netherlands, like other Western countries, shows an obvious demography of aging, which is associated with many challenges. People age differently, after all. Some remain vital until very old age, while others become frail and disabled much earlier in life. Because of the indicated demographic trend, morbidity is expected to increase and with it, the number of older people needing care. 'Aging in place' has become a central phenomenon in healthcare policies. This means that older people should be empowered to lead a meaningful life in their own living environment as long as possible, even when they are frail and care dependent. Therefore, in the future, most care for older people will actually occur at home. This article aims to present a meaningful care model for the older people. Starting from the 'definition discussion' about frailty and a revaluation of the concept of' resilience, a basis will be provided for a sustainable, proactive and personalised elderly care, close to the living environment of older people, in which dentists and other oral health professionals play an important role as well.

P5545Predictors of 10-year mortality and re-intervention in patients with multivessel coronary disease, reduced systolic left ventricular function, after complete revascularization by PCI or CABG

Introduction

In patients with multivessel coronary disease, the decision on revascularization should be made through a heart team. Whether there is an optimal method and what are the predictors of mortality and repeated interventions is the subject of numerous studies.

Purpose

To determine what are the predictors of 10-year mortality and repeated interventions in patients with multivessel coronary disease and reduced systolic left ventricular function in which complete revascularization is done through percutaneous coronary intervention (PCI) and surgical aortocoronary bypass (CABG).

Methods

The survey included 178 patients who underwent elective revascularization of multivessel coronary disease in one center during 2008 through PCI or bypass, according to the heart team's decision. All subjects had a reduced left ventricular systolic function, ejection fraction less than 50%. The study excluded patients with acute coronary syndrome. The basic demographic and clinical characteristics of the subjects and risk factors were analyzed.

Results

Ten-year mortality was 31.4%, without a significant difference between the examined groups (in the PCI group 25 patients (30.5%) in the bypass group 30 (32.3%), p>0.05). In subjects with letal outcome during 10-year follow-up, lower hemoglobin levels in discharge, enlarged cardiac cavities, increased internal diameter of left ventricle in systole (LVIDs) and enlarged left atrium, lower systolic left ventricular function, higher EUROscore and higher NYHA class in discharge. The enlarged left ventricular diameter in systole (OR 2.28 (1.27–4.11), p=0.006) and the NYHA class (OR 2.49 (1.22–5.08), p=0.012) are independent predictors ten-year mortality. In the group of patients undergoing surgical revascularization, independent predictors of 10-year mortality are higher levels of uric acid (OR 1,006 (1,000–1,011), P=0,047) and lower serum hemoglobin at discharge (OR 0,959 (0,919–0,999), P=0.046), while in PCI group LVIDs (OR 2.89 (1.351–6.196), p=0.006). During the 10-year follow-up, repeated PCI was performed in 12 (14.5%) patients in the PCI group and in 3 (3.2%) patients in the CABG group, p=0.012. No surgical revascularization was performed during follow up. Diabetes mellitus is an independent predictor of reintervention in the PCI group (OR 4.12 (1.153–14.703), p=0.029).

Conclusion

Mortality predictors during ten years of follow-up in subjects following a revascularization of multivessel coronary disease, and with reduced left ventricular systolic function, are increased systolic left ventricular diameter and higher NYHA class in discharge. Reintervention is more commonly performed after PCI and the presence of diabetes mellitus is an independent predictor.

P2662Factors associated with in-hospital and long-term mortality in STEMI patients: does primary ventricular fibrillation matter?

Introduction

There are still contrary data about causes and long-term prognosis in patients (pts) with primary ventricular fibrillation (PVF) as a complication of ST-elevation myocardial infarction (STEMI).

Purpose

The aim was to analyze characteristics of STEMI patients associated with PVF occurrence and mortality.

Methods

Our study included 755 pts hospitalised due to STEMI between January 2016 and December 2016. One year follow up was done. Study compared pts with cardiac arrest due to PVF and those without PVF. Only pts treated with urgent coronarography and primary percutaneous coronary intervention (PPCI) in whom TIMI 3 in infarct-related artery was acheved were included. Pts with Killip class 4 as well as pts with mechanical complications or complications due to procedure were excluded.

Results

We found 56/755 (7.42%) STEMI pts had PVF. Compared to pts without PVF (n=699), those with PVF (n=56) were younger (57.8±12.9 vs. 61.8±11.9 years, p 0.02) and more frequently had diabetes mellitus (DM) (52.3% vs. 33.4%, p 0.01) alone or DM with abnormal glucoregulation (AGR) (77.3% vs. 58.4%, p 0.01). Pts with STEMI and PVF had more frequently Killip class 2 (32.7% vs. 21.2%, p 0.02) and class 3 (7.3% vs. 3%, p 0.08), most frequently left anterior descending coronary artery affected (51.8% vs. 36.9%, p 0.03) and proximal occlusion of coronary arteries (44.6% vs. 23%, p 0.000), lower left ventricle ejection fraction (LVEF) (45.4±9.8% vs. 48.7±7.5%, p 0.02), longer duration of hospitalisation (7.3±5.7 vs. 5.7±3.2 days, p 0.001) and higher in-hospital mortality (12.5% vs. 4.9%, p 0.02), but with no difference in long-term mortality (14.3% vs. 11.6%, p 0.40). After multivariable logistic regression analysis (MVLR), model with the differences in proximal coronary artery occlusions (OR 2.4 [95% CI: 1.3–4.7], p 0.008) and DM presence (OR 1.9 [95% CI: 1–3.6], p 0.05) persisted. After one year patients who died compared to those still alive were older (70.8±12.8 vs. 61±11.8 years, p 0.000), more frequently male (52% vs. 32.2%, p 0.01), had higher appearance of anterior wall STEMI (46.7% vs. 24.5%, p 0.001), more frequently Killip class 2 and class 3 (50% vs. 20.9% and 23.5 vs. 2.4% respectively, both p 0.000), lower EF (38.6±10.5 vs. 48.8±7.3%) and higher prevalence of DM (75.8% vs. 32.4%) or DM with AGR (87.9% vs. 57.9%) (both p 0.000). After MVLR model with differences in Killip class 3 (OR 4.2 [95% CI: 1.1–84.6], p 0.000), EF (OR 0.93 [95% CI: 0.87–0.99], p 0.04) and DM presence (OR 3.3 [95% CI: 1.1–10.2], p 0.04), all persisted.

Conclusions

Proximal coronary occlusions and DM presence as indicators of coronary artery disease severity and ischaemic area size are strongly associated with PVF in STEMI patients. Only in-hospital mortality is higher in patients with STEMI and PVF. Long-term mortality in STEMI patients is strongly associated with heart failure (lower EF and higher Killip class) and again DM presence.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Contaminants of emerging concern in freshwater fish from four Spanish Rivers

This study investigated the occurrence of 135 contaminants of emerging concern (CECs) - pharmaceuticals, pesticides, a set of endocrine disrupting compounds (EDCs) (parabens, bisphenols, hormones, triazoles, organophosphorus flame retardants and triclosan), UV-filters, perfluoroalkyl substances (PFASs) and halogenated flame retardants (HFRs) - in 59 fish samples, collected in 2010 in 4 Spanish Rivers (Guadalquivir, Júcar, Ebro and Llobregat). Of the 135 CECs, 76 including 8 pharmaceuticals, 25 pesticides, 10 EDCs, 5 UV-filters, 15 PFASs and 13 HFRs were detected. Pharmaceuticals were the less frequently found and at lower concentrations. Pesticides, EDCs, UV-filters, PFASs and HFRs were detected more frequently (>50% of the samples). The maximum concentrations were 15 ng/g dry weight (dw) for pharmaceuticals (diclofenac), 840 ng/g dw for pesticides (chlorpyrifos), 224 ng/g dw for EDCs (bisphenol A), 242 ng/g dw for UV-filters (EHMC), 1738 ng/g dw for PFASs (PFHxA) and 64 ng/g dw for HFRs (Dec 602). The contaminants detected in fish are commonly detected also in sediments. In light of current knowledge, the risk assessment revealed that there was no risk for humans related to the exposure to CECs via freshwater fish consumption. However, results provide detailed information on the mixtures of CECs accumulated that would be very useful to identify their effects on aquatic biota.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Detection of potentially inappropriate prescribing in older patients with the GheOP³S-tool: completeness and clinical relevance

OBJECTIVES

The Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S-) tool was recently developed as an explicit screening method to detect Potentially Inappropriate Prescribing (PIP) in the community pharmacy. We aimed to validate the GheOP³S-tool as an effective screening method for PIP.

METHODS

All patients admitted to the acute geriatric ward of the Sint-Vincentius hospital (Belgium) were consecutively screened for inclusion (≥70 years,≥5 drugs chronically). PIP prevalence was evaluated by applying the GheOP³S-tool on the complete medication history. For each PIP-item, clinical relevance of the detected item, relevance of proposed alternative and subsequent acceptance by the treating geriatrician and a general practitioner were evaluated. Additionally, contribution to the current admission and preventability was assessed by the geriatrician. The completeness of a PIP-screening with the GheOP³S-tool was evaluated through comparison with the adapted Medication Appropriateness Index (aMAI).

RESULTS

We detected 250 GheOP³S-items in 57 of 60 included patients (95%) (median: four PIP-items per patient; IQR: 3-5). Both the geriatrician and the general practitioners scored the clinical relevance of the detected items 'serious' or 'significant' in over 70% of cases. Proposed alternative treatment plans were accepted for 79% of the PIP-items (n = 198). The aMAI detected 536 items, of which 145 were also detected by the GheOP³S-tool. A total of 119 PIP-items were additionally detected by the GheOP³S-tool.

CONCLUSION

The clinical relevance of the PIP-items detected with the GheOP³S-tool is high, likewise the acceptance rate of proposed alternatives.

Vertical displacement of the centre of mass during walking in people with diabetes and diabetic neuropathy does not explain their higher metabolic cost of walking

People with diabetes display biomechanical gait alterations compared to controls and have a higher metabolic cost of walking (CoW), but it remains unknown whether differences in the vertical displacement of the body centre of mass (CoM) may play a role in this higher CoW. The aim of this study was to investigate vertical CoM displacement (and step length as a potential underpinning factor) as an explanatory factor in the previously observed increased CoW with diabetes. Thirty-one non-diabetic controls (Ctrl); 22 diabetic patients without peripheral neuropathy (DM) and 14 patients with moderate/severe Diabetic Peripheral Neuropathy (DPN), underwent gait analysis using a motion analysis system and force plates while walking at a range of matched speeds between 0.6 and 1.6 m/s. Vertical displacement of the CoM was measured over the gait cycle, and was not different in either diabetes patients with or without diabetic peripheral neuropathy compared to controls across the range of matched walking speeds examined (at 1 m/s: Ctrl: 5.59 (SD: 1.6), DM: 5.41 (1.63), DPN: 4.91 (1.66) cm; p > 0.05). The DPN group displayed significantly shorter steps (at 1 m/s: Ctrl: 69, DM: 67, DPN: 64 cm; p > 0.05) and higher cadence (at 1 m/s: Ctrl: 117 (SD1.12), DM: 119 (1.08), DPN: 122 (1.25) steps per minute; p > 0.05) across all walking speeds compared to controls. The vertical CoM displacement is therefore unlikely to be a factor in itself that contributes towards the higher CoW observed recently in people with diabetic neuropathy. The higher CoW in patients with diabetes may not be explained by the CoM displacement, but rather may be more related to shorter step lengths, increased cadence and the associated increased internal work and higher muscle forces developed by walking with more flexed joints.

Population pharmacokinetic modelling of intravenous paracetamol in fit older people displays extensive unexplained variability

AIMS

Paracetamol is the analgesic most used by older people. The physiological changes occurring with ageing influence the pharmacokinetics (PK) of paracetamol and its variability. We performed a population PK-analysis to describe the PK of intravenous (IV) paracetamol in fit older people. Simulations were performed to illustrate target attainment and variability of paracetamol exposure following current dosing regimens (1000 mg every 6 h, every 8 h) using steady-state concentration (Css-mean ) of 10 mg l-1 as target for effective analgesia.

METHODS

A population PK-analysis, using NONMEM 7.2, was performed based on 601 concentrations of paracetamol from 30 fit older people (median age 77.3 years, range [61.8-88.5], body weight 79 kg [60-107]). All had received an IV paracetamol dose of 1000 mg (over 15 min) after elective knee surgery.

RESULTS

A two-compartment PK-model best described the data. Volume of distribution of paracetamol increased exponentially with body weight. Clearance was not influenced by any covariate. Simulations of the standardized dosing regimens resulted in a Css of 9.2 mg l-1 and 7.2 mg l-1 , for every 6 h and every 8 h respectively. Variability in paracetamol PK resulted in Css above 5.4 and 4.1 mg l-1 , respectively, in 90% of the population and above 15.5 and 11.7, respectively, in 10% at these dosing regimens.

CONCLUSIONS

The target concentration was achieved in the average patient with 1000 mg every 6 h, while every 8 h resulted in underdosing for the majority of the population. Furthermore, due to a large (unexplained) interindividual variability in paracetamol PK a relevant proportion of the fit older people remained either under- or over exposed.

The oral health condition and treatment needs assessment of nursing home residents in Flanders (Belgium)

OBJECTIVES

A study was conducted of nursing home residents with limited access to regular oral health care services to evaluate their oral health status, to perform an assessment of the need for oral treatment and to determine the possible predicting value of age, gender, care dependency and income level on their oral health status and treatment needs.

MATERIALS AND METHODS

Three experienced dentists collected clinical oral health data with a mobile dental unit in 23 nursing homes. Socio-demographic data were extracted from the residents' records in the nursing home. Besides the descriptive and bivariate analysis, a general linear mixed model analysis was also performed with the nursing home as random effect.

RESULTS

The study sample consisted of 1,226 residents with a mean age of 83.9 years, of which 41.9% were edentulous. The mean D₃MFt in the dentate group was 24.5 and 77% needed extractions or fillings. In the group of residents wearing removable dentures, 36.9% needed repair, rebasing or renewal of the denture. The mixed model analysis demonstrated that with each year a resident gets older, the oral health outcomes get worse and that men have worse oral health and higher treatment needs than women. However, the level of income and care dependency had a less extensive role in predicting the oral health outcomes.

CONCLUSIONS

The nursing home residents presented a poor overall oral health status and high dental and prosthetic treatment needs. Gender and age were important predicting variables for the oral health outcomes.

Increasing use of cognitive measures in the operational definition of frailty-A systematic review

Ageing is associated both with frailty and cognitive decline. The quest for a unifying approach has led to a new concept: cognitive frailty. This systematic review explores the contribution of cognitive assessment in frailty operationalization. PubMed, Web of Knowledge and PsycINFO were searched until December 2016 using the keywords aged; frail elderly; aged, 80 and over; frailty; diagnosis; risk assessment and classification, yielding 2863 hits. Seventy-nine articles were included, describing 94 frailty instruments. Two instruments were not sufficiently specified and excluded. 46% of the identified frailty instruments included cognition. Of these, 85% were published after 2010, with a significant difference for publication date (X² = 8.45, p < .05), indicating increasing awareness of the contribution of cognitive deficits to functional decline. This review identified 7 methods of cognitive assessment: dementia as co-morbidity; objective cognitive-screening instruments; self-reported; specific signs and symptoms; delirium/clouding of consciousness; non-specific cognitive terms and mixed assessments. Although cognitive assessment has been increasingly integrated in recently published frailty instruments, this has been heterogeneously operationalized. Once the domains most strongly linked to functional decline will have been identified and operationalized, this will be the groundwork for the identification of reversible components, and for the development of preventive interventional strategies.

Altered Achilles tendon function during walking in people with diabetic neuropathy: implications for metabolic energy saving

The Achilles tendon (AT) has the capacity to store and release elastic energy during walking, contributing to metabolic energy savings. In diabetes patients, it is hypothesized that a stiffer Achilles tendon may reduce the capacity for energy saving through this mechanism, thereby contributing to an increased metabolic cost of walking (CoW). The aim of this study was to investigate the effects of diabetes and diabetic peripheral neuropathy (DPN) on the Achilles tendon and plantarflexor muscle-tendon unit behavior during walking. Twenty-three nondiabetic controls (Ctrl); 20 diabetic patients without peripheral neuropathy (DM), and 13 patients with moderate/severe DPN underwent gait analysis using a motion analysis system, force plates, and ultrasound measurements of the gastrocnemius muscle, using a muscle model to determine Achilles tendon and muscle-tendon length changes. During walking, the DM and particularly the DPN group displayed significantly less Achilles tendon elongation (Ctrl: 1.81; DM: 1.66; and DPN: 1.54 cm), higher tendon stiffness (Ctrl: 210; DM: 231; and DPN: 240 N/mm), and higher tendon hysteresis (Ctrl: 18; DM: 21; and DPN: 24%) compared with controls. The muscle fascicles of the gastrocnemius underwent very small length changes in all groups during walking (~0.43 cm), with the smallest length changes in the DPN group. Achilles tendon forces were significantly lower in the diabetes groups compared with controls (Ctrl: 2666; DM: 2609; and DPN: 2150 N). The results strongly point toward the reduced energy saving capacity of the Achilles tendon during walking in diabetes patients as an important factor contributing to the increased metabolic CoW in these patients. NEW & NOTEWORTHY From measurements taken during walking we observed that the Achilles tendon in people with diabetes and particularly people with diabetic peripheral neuropathy was stiffer, was less elongated, and was subject to lower forces compared with controls without diabetes. These altered properties of the Achilles tendon in people with diabetes reduce the tendon's energy saving capacity and contribute toward the higher metabolic energy cost of walking in these patients.

Towards the understanding of antibiotic occurrence and transport in groundwater: Findings from the Baix Fluvià alluvial aquifer (NE Catalonia, Spain)

Antibiotics are an increasing focus of interest due to their high detection frequency in the environment. However, their presence in water bodies is not regulated by environmental policies. This field study investigates, for the first time, the occurrence, behavior and fate of a selection of 53 antibiotics, including up to 10 chemical groups, in an alluvial aquifer originated from manure application in an agricultural region using hydrogeological, hydrochemical and isotopic approaches. Up to 11 antibiotics were found in groundwater corresponding to 4 different chemical groups: fluoroquinolones, macrolides, quinolones and sulfonamides. In surface water, only 5 different antibiotics from 2 chemical groups: fluoroquinolones and sulfonamides, were quantified. The most frequent antibiotics were sulfamethoxazole and ciprofloxacin. Concentrations of antibiotics were in the order of ng/L, with maximum concentrations of 300ng/L in groundwater. Hydrochemistry and isotopic data and geostatistics confirmed the spatial trend observed for nitrates, where nitrate concentrations tend to be higher in the margin areas of the study area, and lower concentrations are found nearby the river. On the other hand, no clear continuous spatial concentration trend of antibiotics was observed in the aquifer, supported by the short spatial correlation found in the variograms. This indicates that the physical-chemical properties and processes of each antibiotic (mainly, sorption and degradation), and other environmental issues, such as a patchy diffuse input and the manure antibiotic content itself, play an important role in their spatial distribution in groundwater. A discussion on the estimation of the antibiotic sorption parameter reveals the difficulties of describing such phenomena. Furthermore, retardation factors will extend over several orders of magnitude, which highly affects the movement of individual antibiotics within the aquifer. To summarize, this study points out the difficulties associated with antibiotic research in groundwater in order to define water resources quality management strategies and environmental regulations.

[Medication screening by the community pharmacist in Belgium]

About 20% of the European population is older than 65 years. Because of multimorbidity (i.e. multiple chronic condition within a patient), older patients are often prescribed multiple drugs [i.e. polypharmacy). Both older age and polypharmacy significantly increase the risk for adverse drug events. International research showed that more or less 5% of all unplanned hospital admissions is related to the use of medication. About 70% of these drug related admissions happened in patients older than 65 years. Moreover, about half of the admissions could have been avoided. These preventable hospital admissions were caused by the intake of medication without an indication, problems with medication adherence, interactions and/or insufficient monitoring. We define this as (potential Drug Related Problems [DRPI. DRPs can occur on multiple occasions during the medication management process: prescribing, dispensing, intake and monitoring. When DRPs can be detected in an early stage, significant consequences can be avoided. To accomplish this, multiple strategies are possible. One of the possibilities is performing a periodic medication screening by the community pharmacist in patient groups at risk. During such a medication screening, the pharmacotherapy is critically evaluated in a systematic and structured way. The implementation of medication screening in first-line health care is currently limited. The community pharmacist is nevertheless ideally placed to perform this task. There is an important relation of trust between him and the patient and the community pharmacist has access to a full medication history. Furthermore, as an expert in drug-related issues, he possesses all necessary knowledge to perform the pharmacotherapeutic analysis.

Attenuation of pharmaceuticals and their transformation products in a wastewater treatment plant and its receiving river ecosystem

Pharmaceuticals are designed to improve human and animal health, but may also be a threat to freshwater ecosystems, particularly after receiving urban or wastewater treatment plant (WWTP) effluents. Knowledge on the fate and attenuation of pharmaceuticals in engineered and natural ecosystems is rather fragmented, and comparable methods are needed to facilitate the comprehension of those processes amongst systems. In this study the dynamics of 8 pharmaceuticals (acetaminophen, sulfapyridine, sulfamethoxazole, carbamazepine, venlafaxine, ibuprofen, diclofenac, diazepam) and 11 of their transformation products were investigated in a WWTP and the associated receiving river ecosystem. During 3 days, concentrations of these compounds were quantified at the influents, effluents, and wastage of the WWTP, and at different distances downstream the effluent at the river. Attenuation (net balance between removal and release from and to the water column) was estimated in both engineered and natural systems using a comparable model-based approach by considering different uncertainty sources (e.g. chemical analysis, sampling, and flow measurements). Results showed that pharmaceuticals load reduction was higher in the WWTP, but attenuation efficiencies (as half-life times) were higher in the river. In particular, the load of only 5 out of the 19 pharmaceuticals was reduced by more than 90% at the WWTP, while the rest were only partially or non-attenuated (or released) and discharged into the receiving river. At the river, only the load of ibuprofen was reduced by more than 50% (out of the 6 parent compounds present in the river), while partial and non-attenuation (or release) was observed for some of their transformation products. Linkages in the routing of some pharmaceuticals (venlafaxine, carbamazepine, ibuprofen and diclofenac) and their corresponding transformation products were also identified at both WWTP and river. Finally, the followed procedure showed that dynamic attenuation in the coupled WWTP-river system could be successfully predicted with simple first order attenuation kinetics for most modeled compounds.