Potentially inappropriate prescribing among people with dementia in primary care: a retrospective cross-sectional study using the Enhanced Prescribing Database

Background: Little is known about prescribing appropriateness for community-dwelling people with dementia (PWD).
Objective To estimate potentially inappropriate prescribing (PIP) prevalence among PWD in primary care in Northern Ireland, and to investigate associations between PIP and polypharmacy, age and gender.

Methods: A retrospective cross-sectional study was conducted, using data from the Enhanced Prescribing Database. Patients were eligible if a medicine indicated for dementia management was dispensed to them during 01/01/2013 – 31/12/2013. Polypharmacy was indicated by use of ≥4 repeat medications from different drug groups. A subset of the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria, comprising 36 indicators, was applied to the dataset. Overall prevalence of PIP and the prevalence per each STOPP criterion was calculated as a proportion of all eligible persons in the dataset. Logistic regression was used to investigate associations between PIP, polypharmacy, age and gender.

Results: The study population comprised 6826 patients. Polypharmacy was observed in 81.5% (n=5564) of patients. PIP prevalence during the study period was 64.4% (95% CI 63.2 – 65.5; n=4393). The most common instance of PIP was the use of anticholinergic/antimuscarinic medications (n=1718; 25.2%; 95% CI 24.2 – 26.2). In multivariable analyses, both polypharmacy and gender (being female) were associated with PIP, with odds ratios of 7.6 (95% CI 6.6 – 8.7) and 1.3 (95% CI 1.2 – 1.4) respectively. No association was observed between PIP and age, after adjustments for gender and polypharmacy.

Conclusion: This study identified a high prevalence of PIP in community-dwelling PWD. Future interventions may need to focus on certain therapeutic categories and polypharmacy.

FITS into Practice: Translating Research into Practice in Reducing the Use of Anti-psychotic Medication for People with Dementia Living in Care Homes

Objectives: This paper reports on the acceptability and effectiveness of the FITS (Focussed Intervention Training and Support) into Practice Programme. This intervention was scaled up from an earlier cluster randomised-controlled trial that had proven successful in significantly decreasing antipsychotic prescribing in care homes. Method: An in depth 10-day education course in person-centred care was delivered over a three-month period, followed by six supervision sessions. Participants were care-home staff designated as Dementia Care Coaches (DCCs) responsible for implementing interventions in 1 or 2 care homes. The course and supervision was provided by educators called Dementia Practice Development Coaches (DPDCs). Effectiveness data included monitoring antipsychotic prescriptions, goal attainment, knowledge, attitudes and implementation questionnaires. Qualitative data included case studies and reflective journals to elucidate issues of implementation. Results: Of the 100 DCCs recruited, 66 DCCs completed the programme. Pre-post questionnaires demonstrated increased knowledge and confidence and improved attitudes to dementia. Twenty per cent of residents were prescribed antipsychotics at baseline which reduced to 14% (31% reduction) with additional dose reductions being reported alongside improved personalised goal attainment. Crucial for FITS into Practice to succeed was the allocation and protection of time for the DCC to attend training and supervision and to carry out implementation tasks in addition to their existing job role. Evaluation data showed that this was a substantial barrier to implementation in a small number of homes. Discussion and conclusions: The FITS into practice programme was well evaluated and resulted in reduction in inappropriate anti-psychotic prescribing. Revisions to the intervention are suggested to maximise successful implementation.

Coaches' use of and impressions of computer-mediated communication (CMC) media /

The study examined coaches' usage of text-based computer-mediated communication (CMC) media (e.g., text-messaging, email) in the coach-player relationship. Data were collected by surveying Ontario-based male baseball coaches (n = 86) who coached players between 15 and 18 years old. Predictions were made regarding how demographic factors such as age and coaching experience affected coaches' CMC use and opinions. Results indicated that over 76% of respondents never used any CMC media other than email and team websites in their interactions with players. Results also revealed that coaches' usage rates contrasted with their opinion of the usefulness of the media, and their perception of players' use of the media. Coaches characterized most CMC media as limited, unnecessary, and sometimes inappropriate. Additional research should explore players' CMC usage rates and possible guidelines for use of the new media in authority relationships. Academia needs to keep pace with the developments in this area.

Nutrient cycling and nutrient use efficiency in urban and peri-urban agriculture of Kabul, Afghanistan

Like elsewhere also in Kabul, Afghanistan urban and peri-urban agriculture (UPA) has often been accused of being resource inefficient and unsustainable causing negatives externalities to community health and to the surroundings. These arise from the inappropriate management and use of agricultural inputs, including often pesticides and inter-city wastes containing heavy metal residues and pathogens. To address these concerns, parallel studies with the aims of quantification of carbon (C), nitrogen (N), phosphorus (P) and potassium (K) horizontal and vertical fluxes; the assessment of heavy metal and pathogen contaminations of UPA produce, and an economic analysis of cereal, vegetable and grape production systems conducted for two years in UPA of Kabul from April 2008 to October 2009. The results of the studies from these three UPA diverse production systems can be abridged as follows: Biennial net balances in vegetable production systems were positive for N (80 kg ha-1 ), P (75 kg ha-1) and C (3,927 kg ha-1), negative for K (-205 kg ha-1), whereas in cereal production systems biennial horizontal balances were positive for P (20 kg ha-1 ) and C (4,900 kg ha-1) negative for N (-155 kg ha-1) and K (-355 kg ha-1) and in vineyards corresponding values were highly positive for N (295 kg ha-1), P (235 kg ha-1), C (3,362 kg ha-1) and slightly positive for K (5 kg ha-1). Regardless of N and C gaseous emissions, yearly leaching losses of N and P in selected vegetable gardens varied from 70 - 205 kg N ha-1 and 5 - 10 kg P ha-1. Manure and irrigation water contributed on average 12 - 79% to total Inputs of N, P, K and C, 10 - 53% to total inputs of C in the gardens and fields. The elevated levels of heavy metal and pathogen loads on fresh UPA vegetables reflected contamination from increasing traffic in the city, deposits of the past decades of war, lacking collection and treatment of raw inter-city wastes which call for solutions to protect consumer and producer health and increase reliability of UPA productions. A cost-revenue analysis of all inputs and outputs of cereal, vegetable and grapes production systems over two years showed substantial differences in net UPA household income. To confirm these results, more detailed studies are needed, but tailoring and managing the optimal application of inputs to crop needs will significantly enhance farmer’s better revenues as will as environmental and produce quality.

Use of global gene expression patterns in mechanistic studies of oestrogen action in MCF7 human breast cancer cells

Over the years, the MCF7 human breast cancer cell line has provided a model system for the study of cellular and molecular mechanisms in oestrogen regulation of cell proliferation and in progression to oestrogen and antioestrogen independent growth. Global gene expression profiling has shown that oestrogen action in MCF7 cells involves the coordinated regulation of hundreds of genes across a wide range of functional groupings and that more genes are down regulated than upregulated. Adaptation to long-term oestrogen deprivation, which results in loss of oestrogen-responsive growth, involves alterations to gene patterns not only at early time points (0-4 weeks) but continuing through to later times (20-55 weeks), and even involves alterations to patterns of oestrogen-regulated gene expression. Only 48% of the genes which were regulated >= 2-fold by oestradiol in oestrogen-responsive cells retained this responsiveness after long-term oestrogen deprivation but other genes developed de novo oestrogen regulation. Long-term exposure to fulvestrant, which resulted in loss of growth inhibition by the antioestrogen, resulted in some very large fold changes in gene expression up to 10,000-fold. Comparison of gene profiles produced by environmental chemicals with oestrogenic properties showed that each ligand gave its own unique expression profile which suggests that environmental oestrogens entering the human breast may give rise to a more complex web of interference in cell function than simply mimicking oestrogen action at inappropriate times. (C) 2009 Elsevier Ltd. All rights reserved.

Mapping land use in a large agricultural basin : a comparison between classification techniques

In order to facilitate the better management of river basin resources, the Glenelg-Hopkins region in south-east Australia required an accurate and up to date land use map. Land use has a major impact on Australia's natural resources including its soil, water, flora and fauna and plays a major role in determining basin health. Inappropriate land use and practices have contributed to extensive dryland salinity and water quality problems. Land use data is often required for environmental models and in most cases the reliability of model outputs is dependent on the spatial detail and accuracy of the land use mapping. This paper examines methods to obtain an up to date land use map and a detailed accuracy assessment using Landsat ETM+ data for a regional basin. A multi-source based approach allowed the collection of 4817 ground truth data points from the field investigation. This enabled researchers to (i) incorporate a full range of information into digital image analysis with significant improvements in accuracy and (ii) hold sufficient independent references for an accurate error assessment. Classification accuracy was significantly improved using a stratification design, in which the region is sub-divided into smaller homogenous areas as opposed to a full scene classification technique. The overall classification accuracy was 84% (KHAT= 0.833) for the stratified approach compared to 76% (KHAT= 0.743) for the full scene classification. Effective assessment, planning and management of basins are dependent on a sound knowledge of the distribution and variability of land use.

Use of the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) in hospitalised older people

To determine the prevalence and nature of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in patients aged 65 years and over.

Use of the Screening tool of older person's prescriptions (STOPP) in older people admitted to an Australian hospital

Aims: To determine the prevalence of potentially inappropriate medications (PIMs) in older people aged 65years and over who were admitted to hospital, and to examine the medications and medication classes that comprised these PIMs with use of the Screening Tool of Older Person's Prescriptions. Method: Using a retrospective clinical audit design, the medical records of 100 older patients were randomly selected and examined for the prevalence and characteristics of PIMs. The audit was undertaken of patients admitted over a 12-month period to an Australian public teaching hospital. Results: In total, 92 individual occurrences of PIMs were detected, and 54 patients had at least one PIM. The most common type of PIM experienced related to prescribed medications that adversely affected individuals who were prone to falls. Conclusion: Many older patients experienced a PIM during their hospital admission, where the risk of an adverse event could outweigh the clinical benefit.

Potentially inappropriate medications used by the elderly: Prevalence and risk factors in Brazilian care homes

Abstract. Background: The use of potentially inappropriate medications (PIM) among the elderly is a serious public health problem because it is intrinsically linked to increased morbidity and mortality, causing high costs to public health systems. This study's objective was to verify the prevalence of and the factors associated with the use of PIMs by elderly Brazilians in institutional settings. Methods. We performed a transversal study, by consulting the case files of elderly people living in Long Term Care for the Elderly (LTC) in towns in the State of São Paulo, Brazil, as well as structured interviews with the nurses responsible for them.We identified PIMs using the list of recently updated Beers criteria developed by a group of specialists from the American Geriatrics Society (AGS), who reviewed the criteria based on studies with high scientific evidence levels. We defined the factors studied to evaluate the association with PIM use prior to the statistical analyses, which were the chi-square test and multiple logistic regression. Results: Among the elderly who used drugs daily, 82.6% were taking at least one PIM, with antipsychotics (26.5%) and analgesics (15.1%) being the most commonly used. Out of all the medications used, 32.4% were PIMs, with 29.7% of these being PIMs that the elderly should avoid independent of their condition, 1.1% being inappropriate medication for older adults with certain illnesses or syndromes, and 1.6% being medications that older adults should use with caution. In the multivariate analysis, the factors associated with PIM use were: polypharmacy (p = 0.0187), cerebrovascular disease (p = 0.0036), psychiatric disorders (p < 0.0001) and dependency (p = 0.0404). Conclusions: The results of this study showed a high prevalence of PIM use in institutionalized elderly Brazilian patients. and the associated factors were polypharmacy, psychiatric disorders, cerebrovascular diseases and dependency. © 2013 Lima et al.; licensee BioMed Central Ltd.

Evaluation of dentists' knowledge of the use of oral exfoliative cytology in clinical practice

Oral exfoliative cytology (EC) is a rapid and practical complementary test that can be used in the diagnosis of various diseases. The objectives of this study were to assess dentists'knowledge of EC and to disseminate information on the technique. The study included 240 dentists from the city of Anapolis (Goias, Brazil) who answered a questionnaire regarding demographic data and data relating to EC and who then received information on the technique. The data revealed that 26.92% of the dentists did not know about EC. Among those who reported knowledge of EC, 33.91% did not know the procedures for performing the technique, and 85.38% had no experience with EC. In addition, 54.09% of the answers regarding the instrument used to collect the material and 56.82% of the answers concerning suitable fixatives were inappropriate. Although 73.02% of the dentists adequately identified the pathologies for which EC is recommended, it was concluded that the respondents had poor knowledge of EC. There is a need to increase dentists'awareness of this subject and of EC's use in diagnostic practices.

Bromocriptine Treatment for Inappropriate Lactation in Mares: A Case Report

Transient mammary gland development and lactation can occur eventually in weanling foals, yearlings, and adult mares without previous or recent history of pregnancy. The etiology of this condition has not been well documented, and there is limited information on the occurrence, frequency of episodes, composition, and treatment of galactorrhea secretion. This article reports a case of Brazilian Sport Horse mare, aged 10 years, with persistent lactation during 5 months. The treatment consisted of bromocriptine 0.04 mg/kg, b.i.d., orally, for 10 days, associated with hydrotherapy for 20 minutes, twice daily. After 20 days of the treatment onset, the mare was reevaluated, and a significant decrease in the volume of the udder and the amount of secretion produced was noted, and its aspect was clearer (serous) and consisted of more fluid compared with the one collected before treatment. No other clinical alterations or associated diseases were identified. Based on these findings, we suggest the diagnosis of idiopathic inappropriate lactation. Although there is no information about pharmacokinetics and description of the oral bromocriptine use in horses, being a therapeutic option for inappropriate lactation treatment in mares, it was effective at the recommended dosage. (C) 2012 Elsevier Inc. All rights reserved.

Evidence-based clinical use of insulin premixtures

Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient’s clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.

Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

Role Expectations and State Socialization: Germany's Rediscovery of the Use of Force 1990-1995

This dissertation engages the question of why German political elites accepted the use of force during the 1990s and started to commit the country's armed forces to multilateral peacekeeping missions. Previous governments of the Federal Republic had opposed foreign deployment of the military and Germany was characterized by a unique strategic culture in which the efficacy of military force was widely regarded as negative. The rediscovery of the use of force constituted a significant reorientation of German security policy with potentially profound implications for international relations. I use social role theory to explain Germany's security policy reorientation. I argue that political elites shared a national role conception of their country as a dependable and reliable ally. Role expectations of the international security environment changed as a result of a general shift to multilateral intervention as means to address emerging security problems after the Cold War. Germany's resistance to the use of force was viewed as inappropriate conduct for a power possessing the economic and military wherewithal of the Federal Republic. Elites from allied countries exerted social pressure to have Germany contribute commensurate with capabilities. German political elites adapted role behavior in response to external expectations in an effort to preserve the national role conception of a dependable and reliable ally. Security policy reorientation to maintain Germany's national role conception was pursued by conservative elites who acted as 'role entrepreneurs'. CDU/CSU politicians initiated a process of role adaptation to include the use of force for non-defensive missions. They persuaded Social Democrats and Alliance 90/Green party politicians that the maintenance of the country's role conception necessitated a reorientation in security policy to accommodate the changes in the security environment.

Investigation of inappropriate pollutant entries into storm drainage systems : a user's guide /

"Contract number 68-C9-0033 and Cooperative Agreement number CR-816862."