Rahel Naef

Effects of an Advanced Practice Nurse In-Home Health Consultation Program for Community-Dwelling Persons Aged 80 and Older

To evaluate the effects of an advanced practice nurse (APN) in‐home health consultation program (HCP) on quality of life, health indicators (falls, acute events), and healthcare utilization.

Itraconazole Comedication Increases Systemic Levels of Inhaled Fluticasone in Lung Transplant Recipients

Background: After lung transplantation (LTx), inhaled corticosteroids may be prescribed and at the same time prophylaxis against fungal infections with itraconazole is common. In our center, the addition of inhaled fluticasone propionate to systemic immunosuppression resulted in clinical Cushing’s syndrome in 4 lung transplant recipients on itraconazole comedication. Objectives: The current study was undertaken to compare systemic levels of inhaled fluticasone in patients with and without concomitant itraconazole therapy. Methods: The single-center, prospective controlled study was performed in the LTx program in Zurich, Switzerland. Twenty stable recipients, 1–7 years after LTx, on a prednisone maintenance dose (5–7.5 mg/day) gave informed consent and were assigned to 2 groups: (A) without itraconazole comedication and (B) currently on itraconazole, being continued during the study period. The patients of both groups started inhalation of 1 mg fluticasone propionate twice daily for 14 days with a powder disc inhaler. Plasma fluticasone levels were measured before the start of the study and on day 14. Results: Fluticasone levels before starting the treatment were below the detection limit in all 17 patients (7 in group A and 10 in group B) adhering to the study protocol. Baseline characteristics (underlying disease, age at LTx, time since LTx, FEV1) were comparable between the 2 groups. On study day 14, plasma fluticasone levels had increased to detectable levels in all patients (A: 273 ± 124 pg/ml, B: 701 ± 131 pg/ml), i.e. to significantly higher (p = 0.038) concentrations in patients on itraconazole. Conclusions: Itraconazole comedication substantially increases systemic levels of inhaled fluticasone, most likely by inhibiting the cytochrome P450 3A4 enzyme system and thus the clearance of fluticasone. Accumulation of fluticasone can result in increased systemic effects and therefore comedication has to be taken into consideration when inhaled fluticasone is prescribed.

How does psychological processing relate to compliance behaviour after lung transplantation? A content analytical study

Abstract Non-compliance is one of the crucial problems impairing outcome after transplantation. Fourteen lung transplant recipients were interviewed about their thoughts regarding transplant-related topics. Compliance was assessed by doctors. The psychological processing was investigated by content analysis. Highly compliant patients perceived more advantages by transplantation. In contrast, low-compliant patients reported either an emotional distance to the lung or a closer relationship to the donor. Furthermore, they showed a contradictory relationship to the medical staff. There are some indications that perception of advantages by transplantation is crucial to compliance. This experience takes place in the context of a good staff – patient relationship. Emotional distance to the lung or nearness to the donor are further contributing factors of non-compliance.

Forschungsprioritäten der gerontologischen Pflege

In der Schweiz liegt die durchschnittliche Lebenserwartung fur Frauen bei 84 Jahren und fur Manner bei 79 Jahren. Bis ins Jahr 2030 wird die Zahl der uber 80-jahrigen Personen um 83% auf 625 000 zu...In Switzerland life expectancy is currently 84 years in women and 79 years in men. By 2030 the number of people over 80 will increase by 83% to 625 000. The need of nursing care in this population is expected to double. In order to ensure high quality care, scientific knowledge generated by nursing research is, therefore, pivotal. Within the framework of a national project, a nursing research agenda has been formulated based on a literature review, expert panels, a national survey, and a consensus conference; seven priorities for clinical nursing research for the years 2007-2017 have been developed. In the field of gerontological nursing twenty-one research priorities have been identified. They include among others interventions to support independent living and autonomy at home or the impact of new technology on nursing care of the elderly. Support for caregivers and the health of caregivers of patients with dementia have to be addressed as well as interventions for specific challenges in the elderly such as fall prevention, delirium, malnutrition, and depression. Pivotal questions in nursing research are concerned with the continuity of nursing care that exceeds institutional and professional boundaries. Moreover, it is recommended that research projects address the impact of political decisions on nursing care and provide knowledge to improve quality in nursing homes and community health care. With this article the first research agenda for gerontological nursing is presented, that is based on the seven priorities of the Swiss Research Agenda for Nursing-SRAN and in turn can be used as a basis for strategic discussion, action plans, and research projects.

Addition of inhaled fluticasone propionate to systemic immunosuppression after lung transplantation: Cushing's syndrome in patients on itraconazole comedication

Bronchiolitis obliterans syndrome (BOS), the major cause of mortality after lung transplantation (LTx) (1), is difficult to prevent and treat, and the means to decrease its incidence are needed. We have read with interest the article by Whitford et al. (2) reporting the addition of inhaled fluticasone propionate (FP) to systemic immunosuppression after LTx. They found FP to be ineffective for the prevention of BOS (2). Four years ago, we also had started adding inhaled FP to systemic immunosuppression (including prednisone and cyclosporine) in our LTx recipients. Strikingly, four patients developed Cushing’s syndrome (CS). CS was obvious by clinical signs, especially in skin appearance and fat distribution. We compared these patients with four patients receiving FP at the same time who did not develop CS (Table 1). Three males and one female developed CS a few weeks after they were on FP despite unchanged prednisone dosage. Groups were comparable in age, time since LTx, prednisone dosage, and presence of BOS. None of the patients developed BOS de novo. The development of CS while the patients were on inhaled FP was even more surprising because no such features were seen earlier postLTx under a higher prednisone dosage. The glucocorticoid balance in these patients seems to be rather complex (endogenous cortisol, oral prednisone, and inhaled fluticasone). CS patients showed higher serum cortisol and, particularly, dehydroepiandrosterone sulfate levels (Table 1). In contrast, as expected for patients treated with high-dose glucocorticoids, the adrenocorticotropic hormone axis was suppressed in patients without CS. All CS patients and two of the patients without CS were on itraconazole comedication, whereas none of the patients in Whitford’s study was. Itraconazole may inhibit FP metabolism (especially CYP3A4 and possibly P-glycoprotein) and thereby increase its bioavailability. Recently, in a prospective study, we found increased circulating levels of FP in stable LTx patients on itraconazole (3). It is rather difficult to assign the CS phenotype to FP alone. Endogenous adrenocortical hormones would have been expected to be lower in CS patients. In healthy individuals, itraconazole increases plasma concentrations and elimination half-lives of dexamethasone (4) and methylprednisolone (5), thereby enhancing suppression of endogenous cortisol secretion. In our patients with pronounced systemic FP effects such as CS, the opposite seemed to be the case. Itraconazole appears to interfere much more with the metabolism of fluticasone, dexamethasone, and methylprednisolone than with prednisolone and cortisol (3– 5). However, not all individuals on itraconazole and FP developed CS, suggesting additional important parameters such as other comedications or, possibly, polymorphisms in genes encoding peptide chains of the cytochrome P450 (CYP3A4), P-glycoprotein, or glucocorticoid receptors. CS resolved in all of the patients after discontinuation of FP, further suggesting that the inhaled FP caused this systemic side-effect. Our overall experience with FP is consistent with that of Whitford et al., but our findings strongly suggest that inhaled FP is far from being inactive but can become systemically available and have glucocorticoid effects, even to an unwanted extent. On the basis of our observations reported here and elsewhere (3), we strongly recommend that comedication be taken into consideration when inhaled FP is prescribed.