The Geras virtual frailty rehabilitation program to build resilience in older adults with frailty during COVID-19: a randomized feasibility trial

BACKGROUND

The Coronavirus (COVID-19) pandemic has exacerbated the risk for poor physical and mental health outcomes among vulnerable older adults. Multicomponent interventions could potentially prevent or reduce the risk of becoming frail; however, there is limited evidence about utilizing alternative modes of delivery where access to in-person care may be challenging. This randomized feasibility trial aimed to understand how a multicomponent rehabilitation program can be delivered remotely to vulnerable older adults with frailty during the pandemic.

METHODS

Participants were randomized to either a multimodal or socialization arm. Over a 12-week intervention period, the multimodal group received virtual care at home, which included twice-weekly exercise in small group physiotherapy-led live-streamed sessions, nutrition counselling and protein supplementation, medication consultation via a videoconference app, and once-weekly phone calls from student volunteers, while the socialization group received only once-weekly phone calls from the volunteers. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate the feasibility of the program. The main clinical outcomes were change in the 5-times sit-to-stand test (5 × STS) and Depression, Anxiety and Stress Scale (DASS-21) scores. The feasibility outcomes were analyzed using descriptive statistics and expressed as frequencies and mean percent with corresponding confidence intervals (CI). Analysis of covariance (ANCOVA) was used for the effectiveness component.

RESULTS

The program enrolled 33% (n = 72) of referrals to the study (n = 220), of whom 70 were randomized. Adoption rates from different referral sources were community self-referrals (60%), community organizations (33%), and healthcare providers (25%). At the provider level, implementation rates varied from 75 to 100% for different aspects of program delivery. Participant's adherence levels included virtual exercise sessions 81% (95% CI: 75-88%), home-based exercise 50% (95% CI: 38-62%), protein supplements consumption 68% (95% CI: 55-80%), and medication optimization 38% (95% CI: 21-59%). Most participants (85%) were satisfied with the program. There were no significant changes in clinical outcomes between the two arms.

CONCLUSION

The GERAS virtual frailty rehabilitation study for community-dwelling older adults living with frailty was feasible in terms of reach of participants, adoption across referral settings, adherence to implementation, and participant's intention to maintain the program. This program could be feasibly delivered to improve access to socially isolated older adults where barriers to in-person participation exist. However, trials with larger samples and longer follow-up are required to demonstrate effectiveness and sustained behavior change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04500366. Registered August 5, 2020, https://clinicaltrials.gov/ct2/show/NCT04500366.

Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation

BACKGROUND

Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation.

OBJECTIVES

This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month.

METHODS

The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner.

RESULTS

There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231).

CONCLUSION

Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001204730.

Polypharmacy and medicine regimens in older adults in residential aged care

OBJECTIVE

To describe medicines regimens used by older people living in residential aged care facilities (RACFs).

MATERIALS AND METHODS

This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively.

RESULTS

Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade.

CONCLUSION(S)

Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.

Recommendations for outcome measurement for deprescribing intervention studies

Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.

Interventions to address polypharmacy in older adults living with multimorbidity: Review of reviews

OBJECTIVE

To summarize evidence from published systematic reviews evaluating the effect of polypharmacy interventions on clinical and intermediate outcomes. It also summarizes the adverse events that may occur as a result of these interventions.

DATA SOURCES

A literature search was conducted using the electronic databases MEDLINE, Embase, CINAHL, Cochrane Central, and Cochrane Database of Systematic Reviews (PROSPERO registration number: CRD42018085767).

STUDY SELECTION

The search yielded a total of 21,329 citations, of which 619 were reviewed as full text and 5 met the selection criteria.

SYNTHESIS

The polypharmacy interventions were found to produce statistically significant reductions in potentially inappropriate prescribing and improved medication adherence; however, the observed effects on clinical and intermediate outcomes were inconsistent. None of the included reviews reported any significant benefit of polypharmacy interventions for quality-of-life outcomes. Specific to health care utilization and cost, polypharmacy interventions reduced health care resource usage and expenditure. The reviews reported no differences in adverse drug events between polypharmacy interventions and usual care groups. The overall certainty of evidence was reported as low to very low across included reviews.

CONCLUSION

Polypharmacy interventions are associated with reductions in potentially inappropriate prescribing and improvements in medication adherence. However, there is limited evidence of their effectiveness for clinical and intermediate outcomes.

Cost-Utility Analysis of Discontinuing Antidepressants in England Primary Care Patients Compared with Long-Term Maintenance: The ANTLER Study

BACKGROUND

Depression is a common mental health condition with considerable negative impact on health and well-being. Although antidepressants are recommended as first-line treatment, there is limited evidence regarding the cost effectiveness of long-term maintenance antidepressants for preventing relapse.

OBJECTIVES

Our objective was to calculate the mean incremental costs and quality-adjusted life-years (QALYs) over 12 months of discontinuing long-term antidepressant medication in well patients compared with maintenance, using patient-level trial data.

METHODS

We conducted a cost-utility analysis of 478 participants from 150 UK general practices recruited to a randomised, double-blind trial (ANTLER). QALYs were calculated from EQ-5D-5L and 12-Item Short Form survey (SF-12) results, with primary analysis using the EQ-5D-5L value set for England. Resource use was collected from primary care patient electronic medical records and self-completed questionnaires capturing mental-health-related resource use. Costs were calculated by applying standard UK unit costs to resource use. Adjustments were made for baseline variables.

RESULTS

Participants randomised to discontinuation had significantly worse utility scores at 3 months (- 0.032; 95% confidence interval [CI] - 0.053 to - 0.011) but no significant difference in QALYs (- 0.011; 95% CI - 0.026 to 0.003) or costs (£3.11; 95% CI - 41.28 to 47.50) at 12 months. The probability that discontinuation was cost effective compared with maintenance was 12.9% at a threshold of £20,000 per QALY gained.

CONCLUSIONS

Discontinuation of antidepressants was unlikely to be cost effective compared with maintenance for currently well patients on long-term antidepressants. However, this analysis provides no information on the wider impact of antidepressants. Our findings provide information on the potential impact of discontinuing long-term maintenance antidepressants and facilitate improving guidance for shared patient-clinician decision making.

TRIAL REGISTRATION

EudraCT number 2015-004210-26; ISRCTN number ISRCTN15969819.

Polypharmacy and mobility outcomes

Polypharmacy is known to be associated with negative consequences of mobility related conditions such as falls, functional decline and disability. This systematic review highlights the effectiveness of deprescribing interventions on mobility related conditions in older adults in the community dwelling reported taking five or more medications daily.

Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study

Background

There are gaps in knowledge and understanding about the relationships between primary care and community-based health and social services in the context of healthy aging at home and system navigation. This study examined provider perspectives on: a) older adults’ health and social needs; b) barriers to accessing services; c) the nature of relationships between primary care and health and social services; and d) ways to facilitate primary care and health and social services navigation to optimize older adults’ health.

Methods

Four focus groups were conducted involving providers (n = 21) in: urban primary care clinics and health and social services organizations serving older adults in Hamilton, Ontario, Canada. Purposive sampling was employed to recruit community health and social services managers, directors or supervisors and primary health care providers in a Family Health Team via email.

Results

Health and social services needs were exacerbated for community-dwelling older adults with multiple chronic conditions. Strong family/caregiver social support and advocacy was often lacking. Access barriers for older adults included: financial challenges; lack of accessible transportation; wait times and eligibility criteria; and lack of programs to address older adults’ needs. Having multiple providers meant that assessments among providers and older adults resulted in contradictory care pathways. Primary care and health and social services linkages were deficient and complicated by poor communication with patients and health literacy barriers. Primary care had stronger links with other health services than with community-based health and social services; primary care providers were frustrated by the complex nature of health and social services navigation; and care coordination was problematic. Health and social services referred older adults to primary care for medical needs and gathered patient information to gauge program eligibility, but not without challenges.

Conclusions

Results point to strategies to strengthen primary care and health and social services system navigation for older adults including: using a person-focused approach; employing effective primary care and health and social services communication strategies; applying effective system navigation; building trust between primary care and health and social services providers; advocating for improved program access; and adapting services/programs to address access barriers and meet older adults’ needs.

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory

Background

Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers.

Methods

This study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June–July 2015) and 12 months (February–March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings.

Results

Overall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program’s purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes.

Conclusions

This study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams.

Trial registration

ClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

Effect of the Oxygen Potential on the Mo Migration and Speciation in UO2 and UO2+ x

Molybdenum is an abundant element produced by fission in the nuclear fuel UO₂ in a pressurized water reactor. Although its radiotoxicity is low, this element has a key role on the fuel oxidation and other fission products migration, in particular in the case of an accidental scenario. This study aims to characterize the behavior of molybdenum in uranium dioxide as a function of environmental conditions (oxygen partial pressure, high temperature, UO₂ oxidation) typical of an accidental scenario. To do so, molybdenum was introduced in UO₂ or UO_{2+ x} pellets by ion implantation, a technique that allows us to mimic the production of Mo in the nuclear fuel by fission. Then, thermal treatments at high temperature and different oxygen partial pressures were carried out. The mobility of Mo in UO_X samples was followed by secondary ion mass spectrometry (SIMS), while the Mo chemical speciation was investigated by spectroscopic techniques (XANES, Raman). In parallel, ab initio calculations were performed showing the effect of interstitial oxygen atoms on the Mo incorporation sites in UO₂. We show that the Mo mobility is directly connected to its chemical state, which in turn, is linked to the redox conditions. Indeed, under reducing atmosphere, Mo is present in UO₂ or UO_{2+ x} samples under a metallic state Mo(0). Its mobility, being quite low, is driven by a diffusion mechanism. An increase of pO₂ entails the UO₂ and Mo oxidation and, as a consequence, a strong release of this element. We show an increase of the Mo release rate with the increase of the UO_{2+ x} hyper-stoichiometry x. After thermal treatment, Mo remaining in the samples is located in the grains under the MoO₂ form. Our experimental results are assessed by ab initio calculations showing that in the presence of oxygen Mo atoms adopt in UO₂ a local structure close to the octahedral local geometry of Mo oxides.

Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin: 300 cases

OBJECTIVE:

To investigate clinical reports of post-SSRI sexual dysfunction (PSSD), post-finasteride syndrome (PFS) and enduring sexual dysfunction following isotretinoin.

METHODS:

Data from RxISK.org, a global adverse event reporting website, have been used to establish the clinical features, demographic details and clinical trajectories of syndromes of persistent sexual difficulties following three superficially different treatment modalities.

RESULTS

We report on 300 cases of enduring sexual dysfunction from 37 countries following 14 different drugs comprised of serotonin reuptake inhibiting antidepressants, 5α-reductase inhibitors and isotretinoin. While reports of certain issues were unique to the antidepressants, such as the onset of premature ejaculation and persistent genital arousal disorder (PGAD), there was also a significant overlap in symptom profile between the drug groups, with common features including genital anaesthesia, pleasureless or weak orgasm, loss of libido and impotence. Secondary consequences included relationship breakdown and impaired quality of life.

CONCLUSIONS

These data point to a legacy syndrome or syndromes comprising a range of disturbances to sexual function. More detailed studies will require developments in coding systems that recognise the condition(s). Further exploration of these tardive sexual syndromes may yield greater understanding of tardive syndromes in general.

GeriMedRisk, a telemedicine geriatric pharmacology consultation service to address adverse drug events in long-term care: a stepped-wedge cluster randomized feasibility trial protocol (ISRCTN17219647)

Background

Multimorbidity, polypharmacy, and older age predispose seniors to adverse drug events (ADE). Seniors with an ADE experience greater morbidity, mortality, and health care utilization compared to their younger counterparts. To mitigate and manage ADEs among this vulnerable population, we designed a geriatric pharmacology consultation service connecting clinicians with specialist physicians and pharmacists and will investigate the feasibility and acceptability of this complex intervention in the long-term care setting, prior to conducting a larger efficacy trial.

Methods/Design

We will conduct a cluster randomized feasibility trial and qualitative analysis of GeriMedRisk among four long-term care homes in the Waterloo-Wellington region from May 1 to December 31, 2017. The primary outcome is the feasibility and acceptability of GeriMedRisk and the stepped-wedge cluster randomized controlled trial design. We hypothesize that GeriMedRisk is a feasible intervention and its potential to decrease falls and drug-related hospital visits can be evaluated with a stepped-wedge cluster randomized controlled trial design.

Discussion

This mixed methods study will inform a larger efficacy trial of GeriMedRisk's ability to decrease adverse drug events among seniors in the long-term care setting.

Ethics and dissemination

The Hamilton Integrated Research Ethics Board granted the approval for this study protocol 2812. We plan to disseminate the results of this study in peer-reviewed journals and also to our partners and stakeholders.

Trial registration

ISRCTN clinical trials registry, ISRCTN17219647 (March 27, 2017).

Links between serotonin reuptake inhibition during pregnancy and neurodevelopmental delay/spectrum disorders: A systematic review of epidemiological and physiological evidence

OBJECTIVE

To investigate possible linkages between neurodevelopmental delay and neurodevelopmental spectrum disorders and exposure to medication with effects on serotonin reuptake inhibition during pregnancy.

METHODS

We systematically reviewed the epidemiological literature for studies bearing on this relationship in children born with neurodevelopmental spectrum disorder and related conditions, as well as animal studies giving serotonin reuptake inhibitors to pregnant animals and in addition reviewed the literature for proposals as to possible mechanisms that might link effects on serotonin reuptake with cognitive changes post-partum.The epidemiological studies were analysed to produce Forest plots to illustrate possible relations.

RESULTS

The odds ratio of Autistic Spectrum or related Disorders in children born to women taking serotonin reuptake inhibiting antidepressants during pregnancy in case control studies was 1.95 (95% C.I. 1.63, 2.34) and in prospective cohort studies was 1.96 (95% C.I. 1.33, 2.90).

CONCLUSIONS

There appears to be a link between serotonin reuptake inhibition in pregnancy and developmental delay and spectrum disorders in infancy leading to cognitive difficulties in childhood. More work needs to be done to establish more precisely the nature of the difficulties and possible mechanisms through which this link might be mediated.

Fast synthesis of ultrathin ZnO nanowires by oxidation of Cu/Zn stacks in low-pressure afterglow

The synthesis of ultrathin, single-crystalline zinc oxide nanowires was achieved by treating in a flowing microwave plasma oxidation process, zinc films coated beforehand by a sputtered thin buffer layer of copper. The aspect ratio of the nanowires can be controlled by the following experimental parameters: treatment duration, furnace temperature, oxygen concentration. An average diameter of 6 nm correlated with a mean length of 750 nm can be reached with a fairly high surface number density for very short treatments, typically less than 1 min. The oxidized samples are characterized by means of SEM, XRD, SIMS, HRTEM and EDX techniques. Structural characterization reveals that these nanowires are single-crystalline, with the wurtzite phase of ZnO. Nanowires are only composed of ZnO without copper particles inside or at the end of the nanowires. Temperature-dependent photoluminescence measurements confirm that ZnO nanowires are of high crystalline quality and thin enough to produce quantum confinement.

General practitioners' insight into deprescribing for the multimorbid older individual: a qualitative study

INTRODUCTION

The majority of older people with chronic diseases are prescribed multiple medicines resulting in polypharmacy. The extrapolation of the 'single disease model' represented by disease-specific guidelines is a major driver for polypharmacy. Polypharmacy is associated with negative health outcomes. Safely reducing or discontinuing harmful medicines, commonly referred to as deprescribing, has been shown to reduce adverse health outcomes, healthcare costs and mortality. However, there are barriers to deprescribing such as time constraints, limited appropriate clinical resources and the influence of multiple prescribers.

AIM

To explore general practitioners' (GPs') opinions and awareness of deprescribing in an older multimorbid patient.

METHODS

A qualitative study design using face-to-face semi-structured interviews was implemented. GP practices were randomly selected from two cities in New Zealand. Face-to-face in depth interviews were carried out with participants. A hypothetical profile of a multimorbid patient was included to elicit discussions about whether medicines should be continued or discontinued. Interviews were transcribed verbatim for thematic analysis. Transcripts were read and re-read. Themes were identified with iterative building of a coding list until all data were accounted for. Interviews continued until saturation of ideas occurred.

RESULTS

Forty GPs were contacted and 10 consented to participate. Responses to each medicine in the hypothetical patient profile varied. Opinions on deprescribing preventive and symptomatic medicines varied a great deal. Conflicting opinions existed particularly around the prescription of statins, dipyridamole and bisphosphonates. Dilemmas around the appropriate clinical management of reflux disease and insomnia in older people also came to light.

CONCLUSION

Gaining an insight into GPs' current prescribing patterns is important in designing any interventions aimed at reducing inappropriate prescribing. This study highlights the lack of clarity around deprescribing in multimorbidity. The participants' individual responses varied considerably. Deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas and could hence decrease this variation.

Sudden cardiac death & the Reverse Dodo Verdict

Adverse effects of treatment on cardiac QT intervals were first reported 50 years ago. A clear link to sudden death was established, but the problem remained relatively unknown. The issue of treatment related effects on the heart, and the contribution this might make to sudden cardiac deaths in general, came more clearly into focus 20 years ago, linked to regulatory actions. In an era of polypharmacy, and mixing of prescribed and non-prescribed pharmacologically active agents it is now becoming increasingly clear that unanticipated cardiac effects may be common and a significant cause of mortality. There is likely underreporting and also underdiagnosis, as recognition requires a timely ECG. This paper proposes two methods to handle the problem.

Manifesto de Curitiba: pela Prevenção Quaternária e por uma Medicina sem conflitos de interesse

Nós, médicos de família e comunidade reunidos no I Seminário Brasileiro de Prevenção Quaternária, trazemos o seguinte manifesto em prol de uma Medicina isenta de conflitos de interesses e imbuída de profissionalismo no seu sentido mais pleno. Estamos baseados nos seguintes pressupostos: Código de Ética Médica1II - O alvo de toda a atenção do médico é a saúde do ser humano, em benefício da qual deverá agir com o máximo de zelo e o melhor de sua capacidade profissional;IV - Ao médico cabe zelar e trabalhar pelo perfeito desempenho ético da Medicina, bem como pelo prestígio e bom conceito da profissão;V - Compete ao médico aprimorar continuamente seus conhecimentos e usar o melhor do progresso científico em benefício do paciente;IX - A Medicina não pode, em nenhuma circunstância ou forma, ser exercida como comércio;XIV - O médico empenhar-se-á em melhorar os padrões dos serviços médicos e em assumir sua responsabilidadeem relação à saúde pública, à educação sanitária e à legislação referente à saúde;XXIII - Quando envolvido na produção de conhecimento científico, o médico agirá com isenção e independência, visando ao maior benefício para os pacientes e a sociedade;...É vedado ao médico:Art. 68. Exercer a profissão com interação ou dependência de farmácia, indústria farmacêutica, ótica ou qualquer organização destinada à fabricação, manipulação, promoção ou comercialização de produtos de prescrição médica, qualquer que seja sua natureza....É vedado ao médico:Art. 104. Deixar de manter independência profissional e científica em relação a financiadores de pesquisa médica, satisfazendo interesse comercial ou obtendo vantagens pessoais. Conceito de profissão enquanto compromisso com valores profissionaisUma profissão é:1. livre da influência do comércio e do Estado e2. responsável pela sua própria educação e estrutura de conhecimento2 E conceito de Prevenção Quaternária3“Ação feita para identificar pacientes em risco de sobremedicalização, para os proteger de mais intervenções em saúde e para lhes sugerir intervenções eticamente aceitáveis” (Adaptado de Jamoulle e Roland, 1995) Portanto, nós, médicos defensores da prevenção quaternária em qualquer nível de atenção à saúde, defendemos os princípios bioéticos em prol do melhor e do mais aceitável para a população:− Não-maleficência: partindo do pressuposto hipocrático de “em primeiro lugar não causar dano” (primum non nocere), sempre levaremos em conta o fato de que, quanto maior o risco de causar dano, mais embasado cientificamente e isento de interesses diversos do científico deve ser o procedimento em questão para que este possa ser considerado um ato eticamente aceitável, mesmo que para tal se faça necessário questionar aspectos metodológicos e conflitos de interesses em protocolos e diretrizes (muitas destas tidas como conhecimento inquestionável, porém gerado sob uma perspectiva comercial), sempre pautados na melhor evidência cientifica isenta disponível, e evitando ao máximo a “Disease Mongering” (promoção da doença), a transformação de fatores de risco e eventos fisiológicos em doenças, a medicalização desses eventos ou o excesso diagnóstico, que podem por a pessoa em risco de estigmas e danos posteriores.− Beneficência: pensando no melhor para o paciente (do grego pathe – sentimento –, com seus desdobramentos no latim patientem – aquele que sofre –, e pax – paz, paciência), estaremos em busca sempre das melhores e mais adequadas evidências científicas livres de conflitos de interesses para promover a saúde das doenças, com o mínimo de intervenções possíveis. Significa que buscaremos desenvolver ações proativas “para o bem do paciente”, livres de influências externas, lembrando que condutas expectantes ou mesmo a desprescrição também são ações proativas para o benefício das pessoas. E o efeito benéfico envolve também proteger as pessoas de informações inadequadas e reduzir a angústia causada pela Disease Mongering, além de fornecer informações adequadas a essas pessoas para que elas mesmas pesem riscos e benefícios e tomem suas decisões por meio da persuasão puramente profissional-relacional, visando ao melhor resultado possível para aquela pessoa.− Autonomia: a autonomia ou autodeterminação envolve dois aspectos durante o estabelecimento da relação médicopaciente: 1. capacidade para atuar deliberadamente, o que envolve razão e discernimento para decidir entre as alternativas que lhe são apresentadas e 2. liberdade, no sentido de estar livre de qualquer influência controladora para a emissão de um posicionamento.4Portanto, é nossa premissa empoderar a população com as informações mais confiáveis possíveis para a tomada de decisão conjunta diagnóstica ou terapêutica, sem manipulação nem coerção, mas com a avaliação correta de riscos e benefícios, em especial naqueles procedimentos onde ainda há fraco embasamento cientifico e onde há fortes influências de indústrias farmacêuticas ou de produtos médicos-hospitalares, e mesmo de corporações com interesses mercantilistas, indo de encontro aos princípios aqui discorridos. É nossa premissa também tornar as pessoas conhecedoras para uma melhor tomada de decisão, já que o conhecimento, e não a desconfiança, é a melhor ferramenta para a prevenção quaternária.5− Justiça: também é nossa premissa, enquanto promotores e defensores da prevenção quaternária, a luta pelo acesso equânime, justo e apropriado aos recursos em saúde, denunciando a mercantilização da saúde e o uso do sistema sanitário para finalidades diversas do benefício das pessoas, reforçando que justiça e acesso nem sempre estão relacionados às “últimas novidades tecnológicas em saúde”. Nós não cuidamos de órgãos. Nós não promovemos doenças. Nós não superestimamos fatores de risco. Nós cuidamos de pessoas, e pessoas não são números, escores, fatores de risco e nem meros objetos de intervenções. Nós somos cautelosos com resultados surpreendentes de publicações científicas, pois dados podem ser manipulados para diagnosticar sintomas menores ou fatores de risco e assim reduzir os pontos de corte do diagnóstico de uma doença, bem como para criar “pré-doenças”, aumentar o espectro de medicalização e gerar de forma perniciosa lucros para a indústria farmacêutica.6 Nós respeitamos o tempo na ciência e respeitamos a linha do tempo da relação médico-paciente, pois o aspecto relacional na atenção em saúde sempre prevalecerá sobre o aspecto populacional.Por todo o exposto, apontaremos sempre as indústrias e corporações mercantilistas da saúde com seus “achados extraordinários”, lutaremos contra a criação de estigmas e rótulos nas pessoas, lutaremos contra o excesso diagnóstico e terapêutico, promovendo hábitos saudáveis pautados na ciência médica, livres de conflitos de interesses e de vieses de publicações puramente deterministas ou causais, mas acima de tudo promovendo uma boa comunicação com as pessoas para que elas possam também aprender a se proteger do excesso de intervenções em saúde. É nosso papel advogar pela legitimidade na relação profissional-paciente, reconhecendo as incertezas inerentes à ciência médica em si. Devemos orientar o cuidado de forma não normativa, apoiando-se em evidências isentas e permitindo o feedback do paciente, de modo que ele possa interpretar e ajustar a decisão para si enquanto protagonista do seu cuidado.Curitiba, novembro de 2013.

The shipwreck of the singular

In 1962, Louis Lasagna was one of the central figures in the creation of our current drug regulation systems. His influence on the practice of modern medicine, through a series of unanticipated consequences of these systems, has been profound. In the 1960s, he was one of the most progressive thinkers in medicine. By the 1980s, he had apparently become one of the most reactionary. This article attempts to delineate the dilemmas he believed he was dealing with, dilemmas that stemmed from a system he had helped create, that produced this apparent change in orientation. The problems with which he grappled are ones that remain unresolved and indeed, have become more acute. The example of how he attempted to remedy what had gone wrong may provide pointers as to how to solve or how not to solve current difficulties.

Data based medicine and clinical judgement

Randomized controlled trials (RCTs) are a useful tool to check the effectiveness of drugs but have come to shape the culture of medicine in a manner that increasingly compromises medical care. Dependence on RCT evidence is compromised by the well-known problems stemming non-publication of trials, lack of access to trial data, ghostwriting of those trials that are published and a variety of coding and other strategies to hide harms. But what is less appreciated is that whenever a drug and an illness can produce the same benefit or harm that the outcomes of RCTs can be profoundly misleading. This article gives examples of how RCTs can produce the wrong answer.

Clinical care and health disparities

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

Chlamydia trachomatis testing sensitivity in midstream compared with first-void urine specimens

PURPOSE

Traditionally first-void urine specimens are used to test for Chlamydia trachomatis. In contrast, midstream urine specimens are traditionally recommended for microscopy and culture of presumptive bacterial urinary tract infections. The ability to test for both C trachomatis and urinary tract infection on a single midstream urine specimen would greatly aid clinical practice, as an urinary tract infection is an extremely common complaint in primary care. This study set out to determine how well positive C trachomatis results obtained on first-void specimens would correlate with positive findings in matched midstream specimens.

METHODS

One hundred women with a first-void urine specimen positive for C trachomatis also provided midstream specimens for comparison. All specimens had C trachomatis testing performed using a DNA detection method.

RESULTS

Of the 100 eligible participants with a first-void specimen positive for C trachomatis, 96 (96%) also had a positive midstream specimen (95% exact confidence limits, 90.1%, 98.9%).

CONCLUSIONS

These results suggest that by using newer nucleic acid amplification techniques (NAATs), timing of specimen collection is not so important in testing for C trachomatis as previously thought. The sensitivity of NAAT testing on midstream urine specimens in women is sufficiently equivalent to testing on first-void specimens to consider in clinical practice and research settings where first-void specimens have formerly been collected.

Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy

BACKGROUND

Polypharmacy and inappropriate medication use is a problem in elderly patients, who are more likely to experience adverse effects from multiple treatments and less likely to obtain the same therapeutic benefit as younger populations. The Good Palliative-Geriatric Practice algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home inpatients. This study reports the feasibility of this approach in community-dwelling older patients.

METHODS

The Good Palliative-Geriatric Practice algorithm was applied to a cohort of 70 community-dwelling older patients to recommend drug discontinuations. Success rates of discontinuation, morbidity, mortality, and changes in health status were recorded.

RESULTS

The mean (SD) age of the 70 patients was 82.8 (6.9) years. Forty-three patients (61%) had 3 or more and 26% had 5 or more comorbidities. The mean follow-up was 19 months. Participants used a mean (SD) of 7.7 (3.7) medications. Protocol indicated that discontinuation was recommended for 311 medications in 64 patients (58% of drugs; mean [SD], 4.4 [2.5] drugs per patient overall, 4.9 per patient who had discontinuation). Of the discontinued drug therapies, 2% were restarted because of recurrence of the original indication. Taking nonconsent and failures together, successful discontinuation was achieved in 81%. Ten elderly patients (14%) died after a mean follow-up of 13 months, with the mean age at death of 89 years. No significant adverse events or deaths were attributable to discontinuation, and 88% of patients reported global improvement in health.

CONCLUSIONS

It is feasible to decrease medication burden in community-dwelling elderly patients. This tool would be suitable for larger randomized controlled trials in different clinical settings.

Struvite formation from the supernatants of an anaerobic digestion pilot plant

This work studied the influence of the characteristics of the supernatants on the struvite precipitation process. Eighteen experiments with the supernatants generated in an anaerobic digestion pilot plant were performed in a stirred reactor. In order to obtain the pH control during the crystallization process, a Fuzzy Logic based controller was used. High phosphorus precipitation and recovery efficiencies were obtained. The composition of the supernatants was analyzed in order to study its influence on the solids formed from those solutions. The presence of calcium reduced the percentage of phosphorus precipitated as struvite leading to the formation of amorphous calcium phosphate (ACP), which tended to be lost with the effluent of the reactor. Calcite was also formed when supernatants with high magnesium:phosphorus (Mg/P) and calcium:phosphorus (Ca/P) molar ratios were employed. Some ammonium volatilization by conversion to NH(3) occurred in all the experiments. The use of air to increase the pH to an adequate value showed to be feasible. Aeration cleaned struvite crystals from suspended solids, which makes aeration interesting for struvite separation. However, aeration slightly increased the loss of phosphorus with the effluent of the reactor and promoted ammonium volatilization.

An international perspective on the basis for payment for performance

This discussion paper reflects on the pay-for-performance system in UK general practice - the Quality and Outcomes Framework (QOF) - from an international viewpoint. The QOF intends to bring the best scientific evidence to bear on primary care practice. However, the QOF and patient-centred medicine are often at odds. Inadequacies and commercial bias in the creation of evidence make the scientific basis of the QOF questionable. The framework for the QOF does not align well with the scope of primary care, making its basis as a tool for quality measurement questionable. The extent of impact of the QOF on health outcomes and on equity of health outcomes needs examination. Attention to resolution of patients' problems is an important aim of quality improvement activities. Alternative modes of improving patient care may be better than the QOF.

The once and future psychiatry

Psychiatry's traditional strengths have lain in an appreciation of the philosophy and psychology of treatment rather than in an ability to advance the public health through the mass delivery of treatment programs. Given how insecurely established treatment effects are for current interventions, and the capacity for developments in neuroscience to create markets rather than to advance understanding, it seems important to maintain traditional strengths. To have a clinical evidence base, consistent with a wider public health mission, psychiatry would need to track more rigorously the effects of the treatments it now administers before advocating for an even wider distribution of even more interventions with physical treatments than happens at present.

A pilot-scale study of struvite precipitation in a stirred tank reactor: conditions influencing the process

Currently, the two most developed techniques for recovering phosphorus from wastewater consist of the formation of calcium phosphates and struvite (MgNH(4)PO(4).6H(2)O). In this work the influence of the operational conditions on the struvite precipitation process (pH in the reactor, hydraulic retention time, and magnesium:phosphorus, nitrogen:phosphorus, and calcium:magnesium molar ratios) have been studied. Twenty-three experiments with artificial wastewater were performed in a stirred reactor. In order to obtain the pH value maintenance during the crystallization process, a fuzzy logic control has been developed. High phosphorus removal efficiencies were reliably achieved precipitating the struvite as easily dried crystals or as pellets made up of agglomerated crystals.