Withdrawal of Antidementia Drugs in Older People: Who, When and How?

The evidence base to guide withdrawal of antidementia medications in older people with dementia is limited; while some randomised controlled studies have considered discontinuation of cholinesterase inhibitors, no such studies examining discontinuation of the N-Methyl-D-aspartate receptor antagonist memantine have been conducted to date. The purpose of this opinion article was to summarise the existing evidence on withdrawal of cholinesterase inhibitors and memantine, to highlight the key considerations for clinicians when making these prescribing decisions and to offer guidance as to when and how treatment might be discontinued. Until the evidence-base is enhanced by the findings of large scale randomised controlled discontinuation trials of ChEIs and memantine which use multiple, clinically relevant cognitive, functional and behavioural outcome measures, clinicians’ prescribing decisions involve balancing the risks of discontinuation with side-effects and costs of continued treatment. Such decisions must be highly individualised and patient-centred.

Development and Evaluation of a Computer-Based, Self-Management Tool for People Recently Diagnosed with Type 2 Diabetes

Aim. The purpose of this study was to develop and evaluate a computer-based, dietary, and physical activity self-management program for people recently diagnosed with type 2 diabetes. 
Methods. The computer-based program was developed in conjunction with the target group and evaluated in a 12-week randomised controlled trial (RCT). Participants were randomised to the intervention (computer-program) or control group (usual care). Primary outcomes were diabetes knowledge and goal setting (ADKnowl questionnaire, Diabetes Obstacles Questionnaire (DOQ)) measured at baseline and week 12. User feedback on the program was obtained via a questionnaire and focus groups. Results. Seventy participants completed the 12-week RCT (32 intervention, 38 control, mean age 59 (SD) years). After completion there was a significant between-group difference in the “knowledge and beliefs scale” of the DOQ. Two-thirds of the intervention group rated the program as either good or very good, 92% would recommend the program to others, and 96% agreed that the information within the program was clear and easy to understand. 
Conclusions. The computer-program resulted in a small but statistically significant improvement in diet-related knowledge and user satisfaction was high. With some further development, this computer-based educational tool may be a useful adjunct to diabetes self-management.

Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilisation, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimise prescribing for this vulnerable patient group. Although there has been considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life-expectancy is limited. The development of tools to assess medication appropriateness in people with mild-to-moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities and to examine the impact of PIP on health outcomes.

Multiples in the Newborn Intensive Care Unit: parents' and nurses' perspectives

This paper discusses the issues of parents and nurses when mulitples are admitted to busy NICU's

“There’s a Catch-22”. The complexities of pain management for people with advanced dementia nearing the end of life: a qualitative exploration of physicians’ perspectives

Background: Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown. Aim: To explore physicians’ experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges. Design: Qualitative, semi-structured interview study exploring: barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes. Settings/Participants: Twenty-three physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care (n=9), psychiatry (n=7) and hospice care (n=7). Results: Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side-effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialties. Cross-specialty mentoring, and the creation of knowledge networks were believed to improve pain management in this patient population. Conclusions: Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients’ families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail Adults with Limited Life Expectancy): Consensus Validation

Background: To validate STOPPFrail, a list of explicit criteria for potentially inappropriate medications (PIMs) in frailer older adults with limited life expectancy. A Delphi consensus survey of an expert panel (n = 17) comprising specialists in geriatric medicine, clinical pharmacology, palliative care, psychiatry of old age, clinical pharmacy and general practice.
Methods: STOPPFrail criteria was initially created by the authors based on clinical
experience and appraisal of the available literature. Criteria were organised according to physiological system. Each criterion was accompanied by an explanation. Panellists ranked their agreement with each criterion on a 5-point Likert scale and invited to provide written feedback. Criteria with a median Likert response of 4/5 (agree/strongly agree) and a 25th centile of ≥4 were included in the final criteria.
Results: Three Delphi rounds were required. All panellists completed all rounds. Thirty criteria were proposed for inclusion; 26 were accepted. No new criteria were added. The first two criteria suggest deprescribing medications with no indication or where compliance is poor. The remaining 24 criteria include lipid-lowering therapies, alpha-blockers for hypertension, anti-platelets, neuroleptics, proton pump inhibitors, H-2 receptor antagonists, anti-spasmodics, theophylline, leukotriene antagonists, calcium supplements, bone anti-resorptive therapy, selective oestrogen receptor modulators, non-steroidal antiinflammatories, corticosteroids, 5-alpha reductase inhibitors, alpha-1 selective blockers, muscarinic antagonists, oral diabetic agents, ACE-inhibitors, angiotensin receptor blockers, systemic oestrogens, multivitamins, nutritional supplements and prophylactic antibiotics. Anticoagulants and anti-depressants were excluded. Despite incorporation of panellists’ suggestions, memantine and acetyl-cholinesterase inhibitors remained inconclusive.
Conclusion: STOPPFrail comprises 26 criteria, which have been judged by broad consensus, to be potentially inappropriate in frailer older patients with limited life expectancy. STOPPFrail may assist in deprescribing medications in these patients.

L’influence de l’aménagement linguistique sur l'orientation des travaux de terminologie à l’Office québécois de la langue française (1961-2004)

La terminologie, telle quelle se pratique au Québec depuis une cinquantaine d'années, s'inscrit dans un projet d'aménagement linguistique qui vise à faire du français la langue d'utilisation commune sur le territoire québécois. La mise en œuvre de ce projet a été confiée à l'Office québécois de la langue française. Dans le cadre de la présente thèse, nous évaluons l'influence de l'aménagement linguistique sur l'orientation des travaux de terminologie à l'Office québécois de la langue française de 1961 à 2004. Notre objectif principal est de montrer que le projet d'aménagement linguistique a engendré une intense activité terminologique à la suite de l'adoption de diverses lois linguistiques au cours des cinquante dernières années. Plus précisément, nous analysons l'impact de ces lois sur le développement de la pratique de la terminologie. Pour ce faire, nous avons proposé six périodes qui caractérisent les travaux de terminologie de l'Office québécois de la langue française de 1961 à 2004. À l'intérieur de ces six périodes, nous analysons les mandats que les lois linguistiques ont confiés à l'Office et leurs répercussions sur l'orientation de ses travaux terminologiques. À l'instar de la problématique que nous avons esquissée au début de cette thèse, les résultats de notre recherche révèlent que la pratique de la terminologie est liée au projet de société que le Québec s'est donné pour assurer la défense du français sur son territoire. En outre, l'adoption des lois linguistiques a favorisé le développement de la pratique de la terminologie. Cette pratique a évolué en fonction des différents mandats confiés à l'Office québécois de la langue française qui a mis au point une méthodologie de travail en terminologie. C'est dans le cadre de l'aménagement linguistique que la terminologie s'est développée au Québec et qu'elle est devenue l'instrument clé de la mise en œuvre du projet d'aménagement linguistique québécois.

Les pratiques de collaboration entre l'enseignant et l'orthopédagogue dans un contexte d'implantation du modèle Réponse à l'intervention

Depuis 2010, le modèle Réponse à l'intervention (RàI) est de plus en plus prescrit dans les cadres de référence en orthopédagogie des commissions scolaires du Québec (Boudreau et Allard, 2015). D'abord, pour identifier les élèves susceptibles de présenter un trouble d'apprentissage et, parallèlement, pour organiser des services adaptés aux besoins des élèves en difficulté d'apprentissage incluant ceux intégrés à la classe ordinaire. Ce modèle, validé par la recherche s’opérationnalise, entre autres, par l'approche résolution de problème et celle par protocole standardisé (Fuchs et Fuchs, 2007; Marshall, 2010). Ces approches permettent de préciser la pratique pédagogique et orthopédagogique en déterminant puis hiérarchisant les modalités d'intervention et d'évaluation auprès des élèves ciblés en intensification. Or, ce modèle ne définit pas, à l’heure actuelle, la structure collaborative devant être déployée entre l’orthopédagogue et l’enseignant, deux acteurs importants impliqués dans ce modèle d’identification des troubles d'apprentissage (Barnes et Harlacher, 2008), ce qui nous amène à nous intéresser aux pratiques de collaboration entre l'enseignant et l'orthopédagogue dans un contexte d'implantation du modèle RàI. Dans le cadre de ce mémoire, nous visons ainsi à mieux documenter et définir les pratiques de collaboration entre l'enseignant et l'orthopédagogue dans un tel contexte. Pour ce faire, des entretiens semi-dirigés ont été menés afin d'identifier les pratiques de collaboration utilisées, et dégager celles considérées comme exclusives, communes ou conflictuelles. Au total, 30 thèmes ont été identifiés et 85 pratiques sont réparties dans les différents niveaux du modèle RàI.

Élaboration d'un plan d'action d'approvisionnement responsable : cas d'Aéroports de Montréal

De par leurs activités, les aéroports engendrent des impacts environnementaux non négligeables. Un des moyens utilisés pour diminuer leurs impacts environnementaux et sociaux est de réévaluer les exigences dans les appels d’offres et contrats lors de l’acquisition d’un bien ou d’un service pour y intégrer des clauses liées au développement durable. L’approvisionnement responsable est récent en milieu aéroportuaire et possède beaucoup de potentiel compte tenu de l’ampleur et de la diversité des achats qui y sont effectués. Afin de permettre une amélioration continue dans ce domaine, des lignes directrices pour l’élaboration d’un plan d’action d’approvisionnement responsable sont développées. Pour ce faire, un portrait de la situation du développement durable, et plus particulièrement de l’approvisionnement responsable, effectué en analysant le cas de différents aéroports, notamment celui d’Aéroports de Montréal, indique que la responsabilité sociétale d’entreprise est de plus en plus présente et qu’ils sont donc plus conscients de l’importance de connaitre leurs diverses parties prenantes. En ayant connaissance de ses forces et faiblesses en développement durable, grâce à une évaluation BNQ 21000, un plan d’action d’approvisionnement responsable adapté à la réalité d’Aéroports de Montréal est élaboré. Pour ce faire, trois stratégies sont retenues : promouvoir les pratiques d'approvisionnement responsable, favoriser l’implantation de nouvelles pratiques et responsabiliser l'entièreté de la chaîne d'approvisionnement. La première orientation vise principalement à augmenter la communication des efforts et progrès accomplis, la deuxième consiste à apporter quelques ajustements organisationnels pour optimiser les possibilités et la troisième permet d’influencer les fournisseurs à considérer l’approvisionnement responsable dans leur gestion. Néanmoins, certaines pratiques recensées et jugées applicables au sein d’Aéroports de Montréal requièrent plus de temps ou de ressources que sur une période de cinq ans. Ainsi, une stratégie à plus long terme est nécessaire pour assurer une amélioration continue dans le temps. Pour ce faire, il est recommandé de constituer un comité d’approvisionnement responsable pour favoriser une multidisciplinarité et une progression plus rapide. Des pratiques telles que le calcul de coût de propriété, les audits des fournisseurs et de la sensibilisation dans le but de favoriser une plus grande collaboration, nécessitent d’être planifiées dans la stratégie pour optimiser leur implantation avec succès. Le plan d’action intègre les ressources humaines et financières devant être mobilisées afin de préparer les différents départements à la mise en œuvre des pratiques d’approvisionnement proposées.

Littlefield Organ Series presents a Guest Artist Recital: Fabio Ciofini September 25, 2012

Concert Program

Muuttuva lapsen maailma. Minttu-kuvakirjat viidellä vuosikymmenellä 1978–2015.

Tutkimuksen tavoitteena on selvittää, miten kuvaa lapsuudesta rakennetaan verbaalisilla ja visuaalisilla elementeillä kuvakirjan tarjoamien mahdollisuuksien ja rajoitusten puitteissa. Tutkimuskohteinani toimivat Maikki Harjanteen Minttu-kuvakirjoista löytämäni kirjaparit. Samasta aiheesta kirjoitettuja kirjapareja ovat joulusta kertovat kirjat mintun joulu (1979) ja Mintun joulukirja (1989), lemmikin liittymistä Mintun perheeseen käsittelevät kirjat minttu saa koiran (1982) ja Minttu saa oman koiran (2007), mummon nimikkoteokset minttu mummolassa (1978) ja Minttu ja mummo (2010) sekä syntymäpäivistä kertovat kirjat mintun kiva päivä (1979) ja Mintun syntymäpäivät (2014). Tutkin siis, miten kuvaa lemmikeistä, koirista, mummoista, jouluista ja syntymäpäivistä rakennetaan näissä kuvakirjapareissa. Tutkin tutkimuskohteitani ikonoteksteinä eli teoksina, jotka muodostuvat sanan ja kuvan vuorovaikutuksessa. Kuvan ja sanan suhteessa tapahtuneen muutoksen määrittelyn apuna käytän Ulla Rhedinin kolmea kuvakirjakategoriaa sekä Maria Nikolajevan ja Carole Scottin kertovuuden aspektin varaan perustuvaa kuvakirjajaottelua. Representaation ymmärrän Mikko Lehtosen ja Stuart Hallin tapaan kaksisuuntaiseksi ilmiöksi, toisinnoksi, jolla on kuitenkin maailmaa muokkaava voima. Mintut ovat muuttuneet 70-luvun ensimmäisistä kuvakirjoista 2010-luvulle paljon niin visuaalisesti kuin verbaalisesti, mikä on vaikuttanut kirjojen tuottamaan lemmikki-, mummo-, joulu- ja syntymäpäiväkuvaan. Alkutuotannossa painottui kerronnan visuaalinen puoli ja lopputuotannossa tekstin osuus kerronnassa on kasvanut suureksi. Alkutuotannon Mintut pyrkivät mimeettiseen ja realistiseen kuvaukseen kun taas lopputuotanto saa karnevalismin ja nonsensen piirteitä. Samalla Minttujen arvot ovat säilyneet jokseenkin samoina: Vaikka Minttu-kirjoissa representoidaankin melko idyllisesti boheemia lapsiperheen arkea, löytyy niistä säröjä, joilla Mintut kyseenalaistavat valtakulttuuria. Mintut puhuvat vihreiden arvojen puolesta kulutuskulttuuria vastaan ja tekevät selväksi, ettei lapsi tarvitse leluja ja kalliita harrastuksia, vaan oman tärkeän aikuisen aikaa. Minttu-kuvakirjat tuottavat tietynlaista kuvaa lapsuudesta eri vuosikymmenillä. Kuvakirjat luovat omaa todellisuuttaan representoidessaan asioita, eikä niitä voida pitää vallan käytön suhteen neutraalina mediana. Niillä on agenda muuttaa maailmaa.

L'objectivation des pratiques : une activité de formation

[…] Cet essai est une recherche-action explorative et descriptive d'un type de formation continue. Ce travail vise à rapporter, décrire une démarche d'objectivation des pratiques avec des enseignants. De plus, il se veut un moyen précis pour approfondir une réflexion sur une expérience vécue. L'étude se divise en trois grandes parties. Dans la première, nous mettrons en relation la situation actuelle en le vécu pédagogique de l'enseignant qui servira de base à la recherche, le tout confronté à certains modèles théoriques qui serviront de guides tout au long de l'expérience décrite. La deuxième partie vise à décrire l'expérience et enfin la troisième vient tirer des conclusions sur la portée pratique de l’expérience et les orientations possibles.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fuid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution-and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

Origin and ecological selection of core and food-specific bacterial communities associated with meat and seafood spoilage

The microbial spoilage of meat and seafood products with short shelf lives is responsible for a significant amount of food waste. Food spoilage is a very heterogeneous process, involving the growth of various, poorly characterized bacterial communities. In this study, we conducted 16S ribosomal RNA gene pyrosequencing on 160 samples of fresh and spoiled foods to comparatively explore the bacterial communities associated with four meat products and four seafood products that are among the most consumed food items in Europe. We show that fresh products are contaminated in part by a microbiota similar to that found on the skin and in the gut of animals. However, this animal-derived microbiota was less prevalent and less abundant than a core microbiota, psychrotrophic in nature, mainly originated from the environment (water reservoirs). We clearly show that this core community found on meat and seafood products is the main reservoir of spoilage bacteria. We also show that storage conditions exert strong selective pressure on the initial microbiota: alpha diversity in fresh samples was 189 +/- 58 operational taxonomic units (OTUs) but dropped to 27 +/- 12 OTUs in spoiled samples. The OTU assemblage associated with spoilage was shaped by low storage temperatures, packaging and the nutritional value of the food matrix itself. These factors presumably act in tandem without any hierarchical pattern. Most notably, we were also able to identify putative new clades of dominant, previously undescribed bacteria occurring on spoiled seafood, a finding that emphasizes the importance of using culture-independent methods when studying food microbiota.

Collection-Level Subject Access in Aggregations of Digital Collections: Metadata Application and Use

Problems in subject access to information organization systems have been under investigation for a long time. Focusing on item-level information discovery and access, researchers have identified a range of subject access problems, including quality and application of metadata, as well as the complexity of user knowledge required for successful subject exploration. While aggregations of digital collections built in the United States and abroad generate collection-level metadata of various levels of granularity and richness, no research has yet focused on the role of collection-level metadata in user interaction with these aggregations. This dissertation research sought to bridge this gap by answering the question “How does collection-level metadata mediate scholarly subject access to aggregated digital collections?” This goal was achieved using three research methods: • in-depth comparative content analysis of collection-level metadata in three large-scale aggregations of cultural heritage digital collections: Opening History, American Memory, and The European Library • transaction log analysis of user interactions, with Opening History, and • interview and observation data on academic historians interacting with two aggregations: Opening History and American Memory. It was found that subject-based resource discovery is significantly influenced by collection-level metadata richness. The richness includes such components as: 1) describing collection’s subject matter with mutually-complementary values in different metadata fields, and 2) a variety of collection properties/characteristics encoded in the free-text Description field, including types and genres of objects in a digital collection, as well as topical, geographic and temporal coverage are the most consistently represented collection characteristics in free-text Description fields. Analysis of user interactions with aggregations of digital collections yields a number of interesting findings. Item-level user interactions were found to occur more often than collection-level interactions. Collection browse is initiated more often than search, while subject browse (topical and geographic) is used most often. Majority of collection search queries fall within FRBR Group 3 categories: object, concept, and place. Significantly more object, concept, and corporate body searches and less individual person, event and class of persons searches were observed in collection searches than in item searches. While collection search is most often satisfied by Description and/or Subjects collection metadata fields, it would not retrieve a significant proportion of collection records without controlled-vocabulary subject metadata (Temporal Coverage, Geographic Coverage, Subjects, and Objects), and free-text metadata (the Description field). Observation data shows that collection metadata records in Opening History and American Memory aggregations are often viewed. Transaction log data show a high level of engagement with collection metadata records in Opening History, with the total page views for collections more than 4 times greater than item page views. Scholars observed viewing collection records valued descriptive information on provenance, collection size, types of objects, subjects, geographic coverage, and temporal coverage information. They also considered the structured display of collection metadata in Opening History more useful than the alternative approach taken by other aggregations, such as American Memory, which displays only the free-text Description field to the end-user. The results extend the understanding of the value of collection-level subject metadata, particularly free-text metadata, for the scholarly users of aggregations of digital collections. The analysis of the collection metadata created by three large-scale aggregations provides a better understanding of collection-level metadata application patterns and suggests best practices. This dissertation is also the first empirical research contribution to test the FRBR model as a conceptual and analytic framework for studying collection-level subject access.