A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: A study protocol

Background: Therapy for stroke prevention in older persons with atrial fibrillation (AF) is underutilized despite evidence to support its effectiveness. To prevent stroke in this high-risk population, antithrombotic treatment is necessary. Given the challenges and inherent risks of antithrombotic therapy, decision-making is particularly complex for clinicians, necessitating comprehensive risk:benefit assessments. Targeted interventions are urgently needed to support clinicians in this context; the Computerized Antithrombotic Risk Assessment Tool (CARAT) offers a unique approach to this clinical problem. Methods/design. This study (a prospective, cluster-randomized controlled clinical trial) will be conducted across selected regions in the state of New South Wales, Australia. Fifty GPs will be randomized to either the 'intervention' or 'control' arm, with each GP recruiting 10 patients (aged ≥65 with AF); target sample size is 500 patients. GPs in the intervention arm will use CARAT during routine patient consultations to: assess risk factors for stroke, bleeding and medication misadventure; quantify the risk/benefit ratio of antithrombotic treatment, identify the recommended therapy, and decide on the treatment course, for an individual patient. CARAT will be applied by the GP at baseline and repeated at 12 months to identify any changes to treatment requirements. At baseline, the participant (patients and GPs) characteristics will be recorded, as well as relevant practice and clinical parameters. Patient follow up will occur at 1, 6, and 12 months via telephone interview to identify changes to therapy, medication side effects, or clinical events. Discussion. This project tests the utility of a novel decision support tool (CARAT) in improving the use of preventative therapy to reduce the significant burden of stroke. Importantly, it targets the interface of patient care (general practice), addresses the at-risk population, evaluates clinical outcomes, and offers a tool that may be sustainable via integration into prescribing software and primary care services. GP support and guidance in identifying at risk patients for the appropriate selection of therapy is widely acknowledged. This trial will evaluate the impact of CARAT on the prescription of antithrombotic therapy, its longer-term impact on clinical outcomes including stroke and bleeding, and clinicians perceived utility of CARAT in practice. Trial registration. Australian New Zealand Clinical Trials Registry: ACTRN12613000060741. © 2014 Bajorek et al.; licensee BioMed Central Ltd

Contemporary approaches to managing Atrial fibrillation: A survey of Australian general practitioners

© 2015, Australasian Medical Journal Pty Ltd. All rights reserved. Background Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care. Aims To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care. Methods A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas). Results Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in “heart/vascular health”. Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs’ initiation of antithrombotic therapy were: “stroke risk”/”CHADS2 score”, followed by “patients’ adherence/compliance”. GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding. Conclusion Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients’ adherence to therapy a major determinant in decision-making

An Examination of the Feasibility of Linear Deterministic Sea Wave Prediction in Multi-Directional Seas Using Wave Profiling Radar: Theory, Simulation and Sea Trials

This is the final version of the article. Available from the American Meteorological Society via the DOI in this record.For a number of maritime tasks there is a short time period, typically only a few tens of seconds, where a critical event occurs which defines a limiting wave height for the whole operation. Examples are the recovery of fixed and rotary winged aircraft, cargo transfers, final pipe mating in fluid transfer operations and launch/recovery of small craft. The recovery of a 30 ton rescue submersible onto a mother ship in the NATO Submarine Rescue System is a prime example. In such applications short term Deterministic Sea Wave Prediction (DSWP) can play a vital role in extending the sea states under which the system can be safely deployed. DSWP also has great potential in conducting experimental sea wave research at full scale. This report explores the feasibility of using data from an experimental wave profiling radar in achieving DSWP. The report includes theory, simulation and field testing. Two forms of DSWP are employed, a fixed point system based upon a restricted set of wave directions, from which we obtain some success, and the other a fully two dimensional technique, which requires further development. The main finding is that using wave profiling radar for DSWP offers promise but requires improvements both to the spatial reliability and resolution of the wave profiling radar, and to the temporal resolution of its sweep before the technique can be considered to be viable as a usable tool.The authors acknowledge funding from the European Union FP7 and U.K. Ministry of Defence NSRS projects

Concurrent use of prescription drugs and herbal medicinal products in older adults: A systematic review

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.The use of herbal medicinal products (HMPs) is common among older adults. However, little is known about concurrent use with prescription drugs as well as the potential interactions associated with such combinations. Objective Identify and evaluate the literature on concurrent prescription and HMPs use among older adults to assess prevalence, patterns, potential interactions and factors associated with this use. Methods Systematic searches in MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, Web of Science and Cochrane from inception to May 2017 for studies reporting concurrent use of prescription medicines with HMPs in adults (≥65 years). Quality was assessed using the Joanna Briggs Institute checklists. The Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) three stage approach to mixed method research was used to synthesise data. Results Twenty-two studies were included. A definition of HMPs or what was considered HMP was frequently missing. Prevalence of concurrent use by older adults varied widely between 5.3% and 88.3%. Prescription medicines most combined with HMPs were antihypertensive drugs, beta blockers, diuretics, antihyperlipidemic agents, anticoagulants, analgesics, antihistamines, antidiabetics, antidepressants and statins. The HMPs most frequently used were: ginkgo, garlic, ginseng, St John’s wort, Echinacea, saw palmetto, evening primrose oil and ginger. Potential risks of bleeding due to use of ginkgo, garlic or ginseng with aspirin or warfarin was the most reported herb-drug interaction. Some data suggests being female, a lower household income and less than high school education were associated with concurrent use. Conclusion Prevalence of concurrent prescription drugs and HMPs use among older adults is substantial and potential interactions have been reported. Knowledge of the extent and manner in which older adults combine prescription drugs will aid healthcare professionals can appropriately identify and manage patients at risk.Peer reviewedFinal Published versio

Neoliberalism as a Political Rationality: Australian Public Policy Since the 1980s

Since the 1980s, a remarkable transformation has occurred in the rationale that informs public policy in Australia. This transformation reflects a fundamental change in the way national economies and populations are conceived by policy makers and has led to the emergence of new strategies of governance as a consequence. We argue that this change of direction in Australian public policy may be best thought of as a specific neoliberal political rationality. The first section of the paper outlines changes to conceptions of the economy and subjectivity which are associated with neoliberalism as a political rationality. The second part of the paper examines the articulation and implementation of neoliberalism in Australia over the last couple of decades

Enantiomer-Specific Binding of Ruthenium(II) Molecular Wires by the Amine Oxidase of Arthrobacter globiformis

The copper amine oxidase from Arthrobacter globiformis (AGAO) is reversibly inhibited by molecular wires comprising a Ru(II) complex head group and an aromatic tail group joined by an alkane linker. The crystal structures of a series of Ru(II)-wire−AGAO complexes differing with respect to the length of the alkane linker have been determined. All wires lie in the AGAO active-site channel, with their aromatic tail group in contact with the trihydroxyphenylalanine quinone (TPQ) cofactor of the enzyme. The TPQ cofactor is consistently in its active (“off-Cu”) conformation, and the side chain of the so-called “gate” residue Tyr296 is consistently in the “gate-open” conformation. Among the wires tested, the most stable complex is produced when the wire has a −(CH_2)_4− linker. In this complex, the Ru(II)(phen)(bpy)_2 head group is level with the protein molecular surface. Crystal structures of AGAO in complex with optically pure forms of the C4 wire show that the linker and head group in the two enantiomers occupy slightly different positions in the active-site channel. Both the Λ and Δ isomers are effective competitive inhibitors of amine oxidation. Remarkably, inhibition by the C4 wire shows a high degree of selectivity for AGAO in comparison with other copper-containing amine oxidases

Reducing inappropriate polypharmacy: the process of deprescribing

Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies. A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one; (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application

Development of a Core Outcome Set for effectiveness trials aimed at optimising prescribing in older adults in care homes

Background: Prescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS). Methods: A long-list of outcomes was identified through a review of published literature and stakeholder input. Outcomes were reviewed and refined prior to entering a two-round online Delphi exercise and then distributed via a web link to the CHIPPS Management Team, a multidisciplinary team including pharmacists, doctors and Patient Public Involvement representatives (amongst others), who comprised the Delphi panel. The Delphi panellists (n = 19) rated the importance of outcomes on a 9-point Likert scale from 1 (not important) to 9 (critically important). Consensus for an outcome being included in the COS was defined as ≥70% participants scoring 7–9 and <15% scoring 1–3. Exclusion was defined as ≥70% scoring 1–3 and <15% 7–9. Individual and group scores were fed back to participants alongside the second questionnaire round, which included outcomes for which no consensus had been achieved. Results: A long-list of 63 potential outcomes was identified. Refinement of this long-list of outcomes resulted in 29 outcomes, which were included in the Delphi questionnaire (round 1). Following both rounds of the Delphi exercise, 13 outcomes (organised into seven overarching domains: medication appropriateness, adverse drug events, prescribing errors, falls, quality of life, all-cause mortality and admissions to hospital (and associated costs)) met the criteria for inclusion in the final COS. Conclusions: We have developed a COS for effectiveness trials aimed at optimising prescribing in older adults in care homes using robust methodology. Widespread adoption of this COS will facilitate evidence synthesis between trials. Future work should focus on evaluating appropriate tools for these key outcomes to further reduce heterogeneity in outcome measurement in this context

Архетип свобода у контексті французької політичної теорії та історії

Розглянуто сучасні підходи щодо аналізу політичної ментальності. У межах політологічного аналізу окреслено коло проблем, які потребують вирішення з використанням підходів психології. Зроблено висновок про те, що архетип “свобода” становить важливий елемент політичної ментальності французів.Modern approaches of analysis of political mentality are considered. Within the limits of political science analysis outlined circle of problems which need decision with the use of approaches of psychology. A conclusion is done that archetype freedom makes the important element of political mentality of French’s