Traffic Lights Intervention Reduces Therapeutic Inertia: A Randomized Controlled Trial in Multiple Sclerosis Care

Decision making; Disease-modifying therapy; Multiple sclerosisToma de decisiones; Terapia modificadora de la enfermedad; Esclerosis múltiplePresa de decisions; Teràpia modificadora de la malaltia; Esclerosi múltipleBackground: Therapeutic inertia (TI) is a common phenomenon among physicians who care for patients with chronic conditions. We evaluated the efficacy of the traffic light system (TLS) educational intervention to reduce TI among neurologists with MS expertise. Methods: In this randomised, controlled trial, 90 neurologists who provide care to MS patients were randomly assigned to the TLS intervention (n = 45) or to the control group (n = 45). The educational intervention employed the TLS, a behavioral strategy that facilitates therapeutic choices by facilitating reflective decisions. The TLS consisted in a short, structured, single session intervention of 5-7 min duration. Participants made therapeutic choices of 10 simulated case-scenarios. The primary outcome was a reduction in TI based on a published TI score (case-scenarios in which a participant showed TI divided by the total number of scenarios where TI was possible ranging from 0 to 8). Results: All participants completed the study and were included in the primary analysis. TI was lower in the TLS group (1.47, 95% CI 1.32-1.61) compared to controls (1.93; 95% CI 1.79-2.08). The TLS group had a lower prevalence of TI compared to controls (0.67, 95% CI 0.62-0.71 vs. 0.82, 95% CI 0.78-0.86; p = 0.001). The multivariate analysis, adjusted for age, specialty, years of practice, and risk preference showed a 70% reduction in TI for the TLS intervention compared to controls (OR 0.30; 95% CI 0.10-0.89). Conclusions: In this randomized trial, the TLS strategy decreases the incidence of TI in MS care irrespective of age, expertise, years for training, and risk preference of participants, which would lead to better patient outcomes

Dealing with a traumatic past: the victim hearings of the South African truth and reconciliation commission and their reconciliation discourse

In the final years of the twentieth and the beginning of the twenty-first century, there has been a worldwide tendency to approach conflict resolution from a restorative rather than from a retributive perspective. The South African Truth and Reconciliation Commission (TRC), with its principle of 'amnesty for truth' was a turning point. Based on my discursive research of the TRC victim hearings, I would argue that it was on a discursive level in particular that the Truth Commission has exerted/is still exerting a long-lasting impact on South African society. In this article, three of these features will be highlighted and illustrated: firstly, the TRC provided a discursive forum for thousands of ordinary citizens. Secondly, by means of testimonies from apartheid victims and perpetrators, the TRC composed an officially recognised archive of the apartheid past. Thirdly, the reconciliation discourse created at the TRC victim hearings formed a template for talking about a traumatic past, and it opened up the debate on reconciliation. By discussing these three features and their social impact, it will become clear that the way in which the apartheid past was remembered at the victim hearings seemed to have been determined, not so much by political concerns, but mainly by social needs

Overcoming Therapeutic Inertia in Multiple Sclerosis Care: A Pilot Randomized Trial Applying the Traffic Light System in Medical Education

Overcoming Therapeutic Inertia in Multiple Sclerosis Care: A Pilot Randomized Trial Applying the Traffic Light System in Medical Educatio

Atypical antipsychotic medications and hyponatremia in older adults: a population-based cohort study

Background: A number of case reports have suggested a possible association between atypical antipsychotic medications and hyponatremia. Currently, there are no reliable estimates of hyponatremia risk from atypical antipsychotic drugs. Objective: The objective of this study was to examine the 30-day risk of hospitalization with hyponatremia in older adults dispensed an atypical antipsychotic drug relative to no antipsychotic use. Design: The design of this study was a retrospective, population-based cohort study. Setting: The setting of this study was in Ontario, Canada, from 2003 to 2012. Patients: Adults 65 years or older with an identified psychiatric condition who were newly dispensed risperidone, olanzapine, or quetiapine in the community setting compared to adults with similar indicators of baseline health who were not dispensed such a prescription. Measurements: The primary outcome was the 30-day risk of hospitalization with hyponatremia. The tracer outcome (an outcome that is not expected to be influenced by the study drugs) was the 30-day risk of hospitalization with bowel obstruction. These outcomes were assessed using hospital diagnosis codes. Methods: Using health administrative data, we applied a propensity score technique to match antipsychotic users 1:1 to non-users of antipsychotic drugs (58,008 patients in each group). We used conditional logistic regression to compare outcomes among the matched users and non-users. Results: A total of 104 baseline characteristics were well-balanced between the two matched groups. Atypical antipsychotic use compared to non-use was associated with an increased risk of hospitalization with hyponatremia within 30 days (86/58,008 (0.15 %) versus 53/58,008 (0.09 %); relative risk 1.62 (95 % confidence interval (CI) 1.15 to 2.29); absolute risk increase 0.06 % (95 % CI 0.02 to 0.10)). The limited number of events precluded some additional analyses to confirm if the association was robust. Atypical antipsychotic use compared to non-use was not associated with hospitalization with bowel obstruction within 30 days (55/58,008 (0.09 %) versus 44/58,008 (0.08 %); relative risk 1.25 (95 % CI 0.84 to 1.86)). Limitations: We could only study older adults within our data sources. Conclusions: In this study, the use of an atypical antipsychotic was associated with a modest but statistically significant increase in the 30-day risk of a hospitalization with hyponatremia. The association was less pronounced than that described with other psychotropic drugs

State Power and Economic Inefficiency : Explaining Political Failture in Africa

SUMMARY The problem of agricultural crisis in Africa has forced a review of the highly centralised and bureaucratised structures used to provide services to farmers since independence, and has resulted in a return to favour of decentralised market mechanisms. This article traces the historical evolution of the present system in the colonial period, and sets out the theoretical and political assumptions which lay behind its retention in the post?colonial period. It then attempts to account for current failures by examining the theoretical inconsistencies and actual conflicts of interest involved in the attempt to use these structures in the political, economic and social conditions prevailing in post?colonial Africa. It concludes by recommending a more flexible approach based upon the use of decentralised private and cooperative structures directly accountable to the farmers who use them. SOMMAIRE Le problème de la crise agricole en Afrique a forcé une révision des structures bureaucratìques et hautement centralisées, utilisées pour procurer des services aux fermiers depuis l'indépendance, ceci a eu pour résultat de plaider en faveur des mécanismes de marché décentralisées. Cet article trace révolution historique du système actuel dans la période coloniale, et présente les assomptions qui sont derrière son maintien dans la période post?coloniale. On tente ensuite d'expliquer les échecs récents en analysant les contradictions théoriques et les conflits d'intérêt actuels impliqués dans les tentatives d'utiliser ces structures sous des conditions politiques, économiques et sociales prévalant dans l'Afrique post?coloniale. L'article conclut en recommandant une approche plus flexible, basée sur l'utilisation de structures privées décentralisées et des structures coopératives imputables aux fermiers utilisateurs. RESUMEN El problema de la crisis agrícola en Africa ha forzado a una revisión de las estructuras altamente centralizadas y burocráticas utilizadas para proporcionar servicios a los agricultores, resultando en un retorno en favor de los mecanismos descentralizados del mercado. Este artículo describe la evolución histórica del sistema actual en el periodo colonial y establece las hipótesis teóricas y políticas que yacen por detrás de su persistencia en el periodo post?colonial. A continuación intenta explicar los fracasos actuales mediante el examen de las incoherencias teóricas y los conflictos de intereses involucrados en el propósito de utilizar estas estructuras en las condiciones políticas, sociales y económicas prevalecientes en Africa post?colonial. Concluye recomendando un enfoque más flexible basado en el uso de estructuras descentralizadas, tanto privadas como cooperativas, directamente responsables ante los granjeros que las utilizan