Effects of an interprofessional Quality Circle-Deprescribing Module (QC-DeMo) in Swiss nursing homes: a randomised controlled trial.

Potentially inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy. Deprescribing has emerged in the past decade as a safe and effective way to reduce the use of PIMs and improve patient outcomes. However, effective deprescribing interventions are expensive, as they require specialised staff and a great amount of time for each resident. The Quality Circle Deprescribing Module (QC-DeMo) intervention was designed to be less resource-intensive than medication reviews, the current deprescribing gold standard. It consists of a QC session in which physicians, nurses, and pharmacists define a local deprescribing consensus for specific PIMs classes, which is then implemented in the NH. The intervention was trialled in a RCT, with the NH as unit of analysis. After randomisation, intervention NHs enacted the QC-DeMo at the start of the follow-up year. The primary outcomes were the proportion of PIM galenic units and number of PIM defined daily dose per average resident and per day (DDD/res). PIM status was assessed by a combination of the 2015 Beers list and the Norwegian General Practice-Nursing Home criteria. Secondary outcomes were the number of DDD/res to avoid and to reevaluate; safety outcomes were mortality, hospitalisations, falls, and use of physical restraints. Outcomes were evaluated at follow-up using linear regression models, adjusting for the outcome baseline values. Fifty-eight NHs took part in the trial; no individual residents were recruited. The intervention did not reduce the primary outcomes, but a strong trend towards reduction was seen for the number of PIM DDD/res, which accounts for the doses used. PIM DDD/res to reevaluate were significantly reduced, mostly through a reduction in the use of proton-pump inhibitors. Falls and use of physical restraints were not affected, but a statistical interaction between the mission of the NH (geriatric unit or specialised dementia unit) and the intervention group was seen for mortality and hospitalisations. The QC-DeMo intervention can reduce the use of some PIM classes, and could usefully complement other deprescribing interventions. ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018, retrospectively registered

Older adults' attitudes towards deprescribing and medication changes: a longitudinal sub-study of a cluster randomised controlled trial.

To investigate the association between older patients' willingness to have one or more medications deprescribed and: (1) change in medications, (2) change in the appropriateness of medications and (3) implementation of prescribing recommendations generated by the electronic decision support system tested in the 'Optimising PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial. A longitudinal sub-study of the OPTICA trial, a cluster randomised controlled trial. Swiss primary care settings. Participants were aged ≥65 years, with ≥3 chronic conditions and ≥5 regular medications recruited from 43 general practitioner (GP) practices. Patients' willingness to have medications deprescribed was assessed using three questions from the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire and its concerns about stopping score. Medication-related outcomes were collected at 1 year follow-up. Aim 1 outcome: change in the number of long-term medications between baseline and 12 month follow-up. Aim 2 outcome: change in medication appropriateness (Medication Appropriateness Index). Aim 3 outcome: binary variable on whether any prescribing recommendation generated during the OPTICA medication review was implemented. We used multilevel linear regression analyses (aim 1 and aim 2) and multilevel logistic regression analyses (aim 3). Models were adjusted for sociodemographic variables and the clustering effect at GP level. 298 patients completed the rPATD, 45% were women and 78 years was the median age. A statistically significant association was found between the concerns about stopping score and the change in the number of medications over time (per 1-unit increase in the score the average number of medications use was 0.65 higher; 95% CI: 0.08 to 1.22). Other than that we did not find evidence for statistically significant associations between patients' agreement with deprescribing and medication-related outcomes. We did not find evidence for an association between most measures of patient agreement with deprescribing and medication-related outcomes over 1 year. NCT03724539

Physicians', Nurses' and Pharmacists' Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study.

Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents' and relatives' fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients' health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient's wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team

Déprescrire en EMS: regards croisés entre les résidents, leurs proches et les professionnels de la santé [Deprescribing in nursing homes: comparative views of residents, their relatives, and healthcare professionals]

Deprescribing, in order to reduce both polypharmacy and the use of potentially inappropriate medications, remains a challenge, especially in nursing homes. Healthcare professionals perceive residents of these homes as wary of change and reluctant to take part in such endeavours. The results of two studies, one qualitative and the other quantitative, show that, on the contrary, nursing home residents and their relatives would be ready to consider a treatment reduction, provided that time is invested to explain the expected benefits of such changes

Aperçu sur les forêts anciennes et matures de Méditerranée française et des montagnes limitrophes - Enjeux pour la conservation de la nature

Cet article propose un aperçu de la naturalité de 52 peuplements représentatifs de la diversité des hauts lieux forestiers de 15 départements du sud de la France. En moyenne, ils sont caractérisés par une diversité des arbres élevée ; une grande densité de microhabitats ; une structure irrégulière ; une surface terrière > 25 m2/ha ; un âge du peuplement avancé ; un nombre de très très gros bois > 10 TTGB/ha et un volume de bois mort parfois > 50 m3/ha ; une dynamique dominée par les dryades, mais avec une sylvigenèse souvent incomplète. L’empreinte humaine est généralement faible après 1960 mais importante auparavant (pâturage, charbonnage, etc.). La non exploitation du bois est attestée depuis 1880 à La Massane, 1886 à Comus et 1897 à Lente. Les analyses conduisent à l’ordination des peuplements suivant leur naturalité relative. Ceux de plus haute naturalité sont des sapinières ou hêtraies-sapinières (Bois noir de Breil, Zonza, Bois du Chapitre) ou hêtraie (Ventoux, Zicavo, La Massane). Pour les autres habitats, la chênaie verte du Fango–Omita et la chênaie blanche de Montchamp à Païolive sont à remarquer. Ces résultats ouvrent une discussion et des perspectives d’application à la gestion, qu’elle soit productiviste ou conservatoire

Mettre en œuvre un réseau d’îlots de vieux bois - Test d’une méthode dans la Réserve de biosphère du mont Ventoux -

Le réseau d’îlots de vieux bois est un outil nouveau pour conserver notamment la riche biodiversité cavicole et saproxylique. Après avoir analysé la littérature, une méthodologie générique de mise en œuvre, organisée en sept étapes, est proposée, ainsi que des outils pratiques. Elle est testée dans le mont Ventoux. Un scénario défini de façon participative conduit à un réseau d’îlots de sénescence fondé sur des indicateurs de naturalité (indigénat, maturité, ancienneté, connectivité), de même qu’une approche centrée sur les espèces, le manque à gagner économique et la sécurité du public. La surface du réseau d’îlots est limitée à 3% de la surface de la forêt. La méthode Electre est utilisée pour classer les 132 îlots pré-repérés, au regard du scénario élaboré. 74 îlots sont retenus pour le réseau. Les valeurs écologiques sont maximisées. Le manque à gagner est minimisé (66% des îlots retenus présentent un manque à gagner < 20 e/ha/an). La révision de l’aménagement de la forêt domaniale du Ventouret en 2012 a permis la mise en place de quatre premiers îlots, dont un a été financé par Natura 2000. La méthode permet de bien évaluer et hiérarchiser l’intérêt de chaque îlot et de discuter la notion de réseau. Elle est disponible pour être confrontée à des contextes écologiques variés

Stability of Negative Image Equilibria in Spike-Timing Dependent Plasticity

We investigate the stability of negative image equilibria in mean synaptic weight dynamics governed by spike-timing dependent plasticity (STDP). The neural architecture of the model is based on the electrosensory lateral line lobe (ELL) of mormyrid electric fish, which forms a negative image of the reafferent signal from the fish's own electric discharge to optimize detection of external electric fields. We derive a necessary and sufficient condition for stability, for arbitrary postsynaptic potential functions and arbitrary learning rules. We then apply the general result to several examples of biological interest.Comment: 13 pages, revtex4; uses packages: graphicx, subfigure; 9 figures, 16 subfigure

‘The Curse of the Caribbean’? Agency’s impact on the productivity of sugar estates on St. Vincent and the Grenadines, 1814-1829

This study estimates agency’s impact on sugar plantation productivity using a unique early 19th century panel data set from St. Vincent and the Grenadines. Results of fixed effects models, combined with a qualitative and quantitative analysis of potential endogeneity of the agency variable, provide no evidence that estates managed by agents were less productive than those managed by their owners. We discuss the results in the context of the historical and recent, revisionary, interpretations of agency and the emergence of managerial hierarchies in the Atlantic economy

The contribution of insects to global forest deadwood decomposition

The amount of carbon stored in deadwood is equivalent to about 8 per cent of the global forest carbon stocks. The decomposition of deadwood is largely governed by climate with decomposer groups—such as microorganisms and insects—contributing to variations in the decomposition rates. At the global scale, the contribution of insects to the decomposition of deadwood and carbon release remains poorly understood. Here we present a field experiment of wood decomposition across 55 forest sites and 6 continents. We find that the deadwood decomposition rates increase with temperature, and the strongest temperature effect is found at high precipitation levels. Precipitation affects the decomposition rates negatively at low temperatures and positively at high temperatures. As a net effect—including the direct consumption by insects and indirect effects through interactions with microorganisms—insects accelerate the decomposition in tropical forests (3.9% median mass loss per year). In temperate and boreal forests, we find weak positive and negative effects with a median mass loss of 0.9 per cent and −0.1 per cent per year, respectively. Furthermore, we apply the experimentally derived decomposition function to a global map of deadwood carbon synthesized from empirical and remote-sensing data, obtaining an estimate of 10.9 ± 3.2 petagram of carbon per year released from deadwood globally, with 93 per cent originating from tropical forests. Globally, the net effect of insects may account for 29 per cent of the carbon flux from deadwood, which suggests a functional importance of insects in the decomposition of deadwood and the carbon cycle