Surgical preferences of patients at risk of hip fractures: hemiarthroplasty versus total hip arthroplasty

BACKGROUND: The optimal treatment of displaced femoral neck fractures in patients over 60 years is controversial. While much research has focused on the impact of total hip arthroplasty (THA) and hemiarthroplasty (HA) on surgical outcomes, little is known about patient preferences for either alternative. The purpose of this study was to elicit surgical preferences of patients at risk of sustaining hip fracture using a novel decision board. METHODS: We developed a decision board for the surgical management of displaced femoral neck fractures presenting risks and outcomes of HA and THA. The decision board was presented to 81 elderly patients at risk for developing femoral neck fractures identified from an osteoporosis clinic. The participants were faced with the scenario of sustaining a displaced femoral neck fracture and were asked to state their treatment option preference and rationale for operative procedure. RESULTS: Eighty-five percent (85%) of participants were between the age of 60 and 80 years; 89% were female; 88% were Caucasian; and 49% had some post-secondary education. Ninety-three percent (93%; 95% confidence interval [CI], 87-99%) of participants chose THA as their preferred operative choice. Participants identified several factors important to their decision, including the perception of greater walking distance (63%), less residual pain (29%), less reoperative risk (28%) and lower mortality risk (20%) with THA. Participants who preferred HA (7%; 95% CI, 1-13%) did so for perceived less invasiveness (50%), lower dislocation risk (33%), lower infection risk (33%), and shorter operative time (17%). CONCLUSION: The overwhelming majority of patients preferred THA to HA for the treatment of a displaced femoral neck fracture when confronted with risks and outcomes of both procedures on a decision board

A spontaneous mutation in MutL-Homolog 3 (HvMLH3) affects synapsis and crossover resolution in the barley desynaptic mutant des10

Although meiosis is evolutionarily conserved, many of the underlying mechanisms show species-specific differences. These are poorly understood in large genome plant species such as barley (Hordeum vulgare) where meiotic recombination is very heavily skewed to the ends of chromosomes. The characterization of mutant lines can help elucidate how recombination is controlled. We used a combination of genetic segregation analysis, cytogenetics, immunocytology and 3D imaging to genetically map and characterize the barley meiotic mutant DESYNAPTIC 10 (des10). We identified a spontaneous exonic deletion in the orthologue of MutL-Homolog 3 (HvMlh3) as the causal lesion. Compared with wild-type, des10 mutants exhibit reduced recombination and fewer chiasmata, resulting in the loss of obligate crossovers and leading to chromosome mis-segregation. Using 3D structured illumination microscopy (3D-SIM), we observed that normal synapsis progression was also disrupted in des10, a phenotype that was not evident with standard confocal microscopy and that has not been reported with Mlh3 knockout mutants in Arabidopsis. Our data provide new insights on the interplay between synapsis and recombination in barley and highlight the need for detailed studies of meiosis in nonmodel species. This study also confirms the importance of early stages of prophase I for the control of recombination in large genome cereals.Isabelle Colas, Malcolm Macaulay, James D. Higgins, Dylan Phillips, Abdellah Barakate ... Robbie Waugh ... et al

Vision, challenges and opportunities for a Plant Cell Atlas

With growing populations and pressing environmental problems, future economies will be increasingly plant-based. Now is the time to reimagine plant science as a critical component of fundamental science, agriculture, environmental stewardship, energy, technology and healthcare. This effort requires a conceptual and technological framework to identify and map all cell types, and to comprehensively annotate the localization and organization of molecules at cellular and tissue levels. This framework, called the Plant Cell Atlas (PCA), will be critical for understanding and engineering plant development, physiology and environmental responses. A workshop was convened to discuss the purpose and utility of such an initiative, resulting in a roadmap that acknowledges the current knowledge gaps and technical challenges, and underscores how the PCA initiative can help to overcome them.</jats:p

Provision of Clinical Pharmacy Services in the Home to Patients Recently Discharged from Hospital: A Pilot Project

ABSTRACTBackground: Home care is an increasingly important component of Canada’s health care system. Despite the array of often-complex medication regimens used in home care, pharmacists have not traditionally been members of home care teams. Also, there is minimal literature describing pharmacist involvement in home care in Canada.Objectives: To determine the rate of identification of medication-related issues by a pharmacist providing home care, the rate of acceptance of the pharmacist’s recommendations and the significance of those recommendations, the types of clinical pharmacy services performed and the resources required to do so, and the satisfaction of patients and the health care team with the services provided by the pharmacist.Methods: Clinical pharmacy services were provided at home to patients who had recently been discharged from hospital and who were at high risk of adverse drug events. Services were provided for at least 3 weeks. Examples of services included comprehensive or focused assessment of the medication regimen, assessment of adverse drug events, and assessment of adherence. The pharmacist kept detailed records of the clinical pharmacy services provided to each patient, which were subsequently analyzed to determine the frequency of particular problems and the outcome of the pharmacist’s recommendations to resolve them.Results: Thirty patients were initially identified, but the analysis is based on the 27 patients (mean age 81.1 years) who received at least one visit from the pharmacist. The mean number of medications per patient was 11.9, the mean number of medication- related issues identified was 3.6, and the mean number of recommendations was 4.3. Of the 53 recommendations made to physicians, 39 (74%) were accepted, and 3 (6%) were rejected; the response to 11 (21%) of the recommendations was unknown. On a scale of 1 to 6, the mean significance of the recommendations was 4.1. Overall satisfaction scores (on a scale from 0 to 10) were 9.6 for health care team members and 9.9 for patients.Conclusions: A variety of medication-related issues were identified for home care patients who had recently been discharged from hospital, and many of the clinically significant recommendations that the pharmacist made to optimize medication regimens were accepted. Patients and other members of the health care team were very satisfied with the clinical pharmacy services provided.RÉSUMÉHistorique : Les soins à domicile occupent une part de plus en plus important du système de soins de santé canadien. Malgré une panoplie souvent complexe de traitements médicamenteux utilisés à domicile, les pharmaciens ne font pas partie traditionnellement des équipes de soins à domicile. De plus, la littérature fait peu état de la participation des pharmaciens aux soins à domicile. Objectifs : Déterminer le taux d’identification des problèmes liés à la pharmacothérapie par un pharmacien qui participe à la prestation des soins à domicile, le taux d’acceptation des recommandations du pharmacien, l’importance de ces recommandations, les types de services de pharmacie clinique et les ressources utilisées pour leur prestation, ainsi que la satisfaction des patients et de l’équipe de soins envers les services du pharmacien.Méthodes : Des services de pharmacie clinique ont été fournis à domicile à des patients qui venaient d’obtenir leur congé de l’hôpital et qui présentaient un risque élevé d’événements indésirables liés aux médicaments. Les services ont été fournis pendant au moins trois semaines, et comprenaient notamment une évaluation exhaustive ou ciblée des traitements médicamenteux, une évaluation des événements indésirables des médicaments et une évaluation de l’observance thérapeutique. Le pharmacien a consigné minutieusement les services de pharmacie clinique fournis à chaque patient, puis ces dossiers ont été subséquemment analysés pour déterminer la fréquence de certains problèmes et le résultat des solutions recommandées par le pharmacien.Résultats : Trente patients ont d’abord été sélectionnés pour participer à ce projet, mais l’analyse n’a porté que sur les 27 patients (âge moyen de 81,1 ans) qui ont reçu au moins une visite du pharmacien. Le nombre moyen de médicaments par patient était de 11,9, celui des problèmes liés à la pharmacothérapie identifiés de 3,6, et le nombre moyen de recommandations de 4,3. Des 53 recommandations formulées aux médecins, 39 (74 %) ont été acceptées, et 3 (6 %) rejetées; on ignore quelle a été la réponse à 11 (21 %) de recommandations. Sur une échelle de 1 à 6, l’importance moyenne des recommandations était de 4,1. La cote de satisfaction globale (sur une échelle de 0 à 10) était de 9,6 pour les membres de l’équipe de soins et de 9,9 pour les patients.Conclusions : Divers problèmes liés à la pharmacothérapie ont été identifiés chez les patients qui venaient de recevoir leur congé de l’hôpital et qui recevaient des soins à domicile, et un grand nombre des recommandations significatives sur le plan clinique que le pharmacien a formulées pour optimiser les traitements médicamenteux ont été acceptées. Les patients et les membres de l’équipe de soins étaient très satisfaits des services de pharmacie clinique

Application of the Beers Criteria to Alternate Level of Care Patients in Hospital Inpatient Units

ABSTRACTBackground: The Beers criteria were developed to help in identifying potentially inappropriate medications (PIMs) for elderly patients. These medications are often associated with adverse events and limited effectiveness in older adults. Patients awaiting an alternate level of care (ALC patients) are those who no longer require acute care hospital services and are waiting for placement elsewhere. They are often elderly, have complex medication regimens, and are at high risk of adverse events. At the time of this study no studies had applied the Beers criteria to ALC patients in Canadian hospitals.Objectives: To determine the proportion of ALC patients receiving PIMs and the proportion experiencing selected PIM-related adverse events. Methods: A retrospective chart review of ALC patients 65 years of age or older was performed to identify PIMs and the occurrence of selected adverse events (specifically central nervous system [CNS] events, falls, bradycardia, hypoglycemia, seizures, insomnia, gastrointestinal bleeding, and urinary tract infections). A logistic regression model with a random intercept for each patient was constructed to estimate odds ratios and probabilities of adverse events.Results: Fifty-two ALC patients were included in the study. Of these, 48 (92%) were taking a PIM. Of the 922 adverse events evaluated, 407 (44.1%) were associated with a regularly scheduled PIM. Among patients who were taking regularly scheduled PIMs, there was a significantly increased probability of an adverse CNS event and of a fall (p &lt; 0.001 for both). The most common PIM medication classes were first-generation antihistamines (24 [46%] of the 52 patients), antipsychotics (21 patients [40%]), short-acting benzodiazepines (15 patients [29%]), and nonbenzodiazepine hypnotics (14 patients [27%]).Conclusions: A high proportion of ALC patients were taking PIMs and experienced an adverse event that may have been related to these drugs. These findings suggest that the ALC population might benefit from regular medication review and monitoring to prevent or detect adverse events.RÉSUMÉContexte : Les critères de Beers ont été élaborés afin d’aider à détecter l’utilisation de médicaments potentiellement inappropriés (MPI) auprès des patients âgés. L’on associe souvent les MPI à des événements indésirables, et leur efficacité chez les personnes âgées est limitée. Les patients en attente d’un autre niveau de soins (patients ANS) sont ceux qui ne nécessitent plus de soins de courte durée de l’hôpital et qui attendent d’être déplacés vers un autre établissement. Il s’agit souvent de personnes âgées ayant une panoplie complexe de traitements médicamenteux et présentant un risque élevé de subir des événements indésirables. Au moment de la présente recherche, aucune étude n’avait appliqué les critères de Beers aux patients ANS des hôpitaux canadiens.Objectifs : Déterminer quelles sont les proportions de patients ANS qui reçoivent des MPI et qui subissent certains événements indésirables choisis liés à ces médicaments.Méthodes : Une analyse rétrospective des dossiers médicaux de patients ANS âgés de 65 ans et plus a été réalisée dans le but de relever les MPI ainsi que les cas de certains événements indésirables choisis (particulièrement les événements liés au système nerveux central, les chutes, la bradycardie, l’hypoglycémie, les convulsions, l’insomnie, les hémorragies gastro-intestinales et les infections urinaires). On a mis au point un modèle de régression logistique avec ordonnée à l’origine aléatoire pour chaque patient afin d’estimer les risques relatifs approchés ainsi que les probabilités d’événements indésirables.Résultats : Au total, 52 patients ANS ont été admis à l’étude. De ceuxci, 48 (92 %) prenaient un MPI. Des 922 événements indésirables analysés, 407 (44,1 %) ont été associés à un MPI administré régulièrement. Parmi les patients prenant des MPI à une fréquence régulière, la probabilité de subir une chute ou un événement indésirable lié au système nerveux central était grandement accrue (p &lt; 0,001 pour chacun). Les MPI les plus fréquents étaient : les antihistaminiques de première génération (24 [46 %] des 52 patients), les antipsychotiques (21 patients [40 %]), les benzodiazépines à action brève (15 patients [29 %]) et les hypnotiques non-benzodiazépines (14 patients [27 %]).Conclusions : Un grand nombre de patients ANS prenaient des MPI et avaient subi un événement indésirable qui ouvait avoir été en lien avec ces médicaments. Ces résultats laissent croire que les patients ANS pourraient tirer avantage d’évaluations fréquentes de la pharmacothérapie et de surveillance afin de prévenir les événements indésirables ou de les détecter

Application of the Beers Criteria to Alternate Level of Care Patients in Hospital Inpatient Units

BACKGROUND: The Beers criteria were developed to help in identifying potentially inappropriate medications (PIMs) for elderly patients. These medications are often associated with adverse events and limited effectiveness in older adults. Patients awaiting an alternate level of care (ALC patients) are those who no longer require acute care hospital services and are waiting for placement elsewhere. They are often elderly, have complex medication regimens, and are at high risk of adverse events. At the time of this study no studies had applied the Beers criteria to ALC patients in Canadian hospitals. OBJECTIVES: To determine the proportion of ALC patients receiving PIMs and the proportion experiencing selected PIM-related adverse events. METHODS: A retrospective chart review of ALC patients 65 years of age or older was performed to identify PIMs and the occurrence of selected adverse events (specifically central nervous system [CNS] events, falls, bradycardia, hypoglycemia, seizures, insomnia, gastrointestinal bleeding, and urinary tract infections). A logistic regression model with a random intercept for each patient was constructed to estimate odds ratios and probabilities of adverse events. RESULTS: Fifty-two ALC patients were included in the study. Of these, 48 (92%) were taking a PIM. Of the 922 adverse events evaluated, 407 (44.1%) were associated with a regularly scheduled PIM. Among patients who were taking regularly scheduled PIMs, there was a significantly increased probability of an adverse CNS event and of a fall (p < 0.001 for both). The most common PIM medication classes were first-generation antihistamines (24 [46%] of the 52 patients), antipsychotics (21 patients [40%]), short-acting benzodiazepines (15 patients [29%]), and nonbenzodiazepine hypnotics (14 patients [27%]). CONCLUSIONS: A high proportion of ALC patients were taking PIMs and experienced an adverse event that may have been related to these drugs. These findings suggest that the ALC population might benefit from regular medication review and monitoring to prevent or detect adverse events

Development and randomised controlled trial of a Continence Product Patient Decision Aid for men post-radical prostatectomy

Aims and objectives: to develop and evaluate an evidence‐based Continence Product Patient Decision Aid (CP‐ PDA) to reduce decisional conflict and support continence product choice for men post‐radical prostatectomy.Background: in 2018, 1.3 million men globally were diagnosed with prostate cancer. A common treatment is radical prostatectomy, usually leading to sudden‐onset of urinary incontinence. For people experiencing incontinence, products to contain leakage are fundamental to health‐related quality‐of‐life, but many product users and healthcare professionals are unaware of available options. No evidence‐based guidance on choosing products exists despite known physical and psychological burdens of poorly managed leakage (e.g. isolation, anxiety, depression, skin‐damage).Design and Methods: 4 phases, underpinned by international decision‐aid guidance.Evidence/expert opinion: literature review; consultation with specialist continence clinicians (n=7) to establish evidence‐base.Prototype: CP‐PDA developed with continence specialist (n=7) feedback. Alpha testing (stakeholders): CP‐PDA materials were provided to expert patients (n=10) and clinicians (n=11) to assess content/presentation. Beta testing (field) following CONSORT guidelines, registered NIHR CPMS 31077: men (n=50) post‐radical prostatectomy randomised to evaluate usability and decision‐making using the Decisional Conflict Scale compared with usual care.Results: an algorithm differentiating patients by mobility, dependency, cognitive impairment and type/level of leakage, leading to 12 user groups was developed. For each group, an option table and associated product information sheets guide product choice. Total Decisional Conflict Score for men using the CP‐PDA was significantly better than for men without. CP‐PDA users reported greater confidence in product knowledge and choice.Conclusion: his is the first evidence‐based CP‐PDA, developed using an internationally recognised method. Compared to usual care, it significantly reduced decisional conflict for men choosing continence products post‐prostatectomy.Relevance to clinical Practice: the CP‐PDA provides nurses with the first comprehensive, evidence‐based intervention to help post‐prostatectomy men in complex continence product choices. An online version is available: www.continenceproductadvisor.org.<br/