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

Inhibition of tumour necrosis factor-alpha by antisense targeting produces immunophenotypical and morphological changes in injury-activated microglia and macrophages

Microglia respond in a stereotypical pattern to a diverse array of pathological states. These changes are coupled to morphological and immunophenotypical alterations and the release of a variety of reactive species, trophic factors and cytokines that modify both microglia and their cellular environment. We examined whether a microglial-produced cytokine, tumour necrosis factor-alpha (TNF-alpha), was involved in the maintenance of microglial activation after spinal cord injury by selective inhibition using TNF-alpha antisense deoxyoligonucleotides (ASOs). Microglia and macrophages harvested from 3 d post-contused rat spinal cord were large and rounded (86.3 +/- 9.6%). They were GSA-IB4-positive (GSA-IB4(+)) (Griffonia simplicifolia lectin, microglia specific; 94.8 +/- 5.1%), strongly OX-42 positive (raised against a type 3 complement/integrin receptor, CD11b; 78.9 +/- 9.1%), ED-1 positive (a lysosomal marker shown to correlate well with immune cell activation; 97.2 +/- 2.6%) and IIA positive (antibody recognizes major histocompatibility complex II; 57.2 +/- 5.6%), indicative of fully activated cells, for up to 48 h after plating. These cells also secreted significant amounts of TNF-alpha (up to 436 pg/microg total protein, 16 h). Fluoroscein isothiocyanate-labelled TNF-alpha ASOs (5, 50 and 200 nm) added to the culture medium were taken up very efficiently into the cells (> 90% cells) and significantly reduced TNF-alpha production by up to 92% (26.5 pg/microg total protein, 16 h, 200 nm TNF-alpha ASOs). Furthermore, few of the treated cells at this time were round (5.4 +/- 2.7%), having become predominantly spindle shaped (74.9 +/- 6.3%) or stellate (21.4 +/- 2.7%); immunophenotypically, although all of them remained GSA-IB4 positive (91.6 +/- 6.2%), many were weakly OX-42 positive and few expressed either ED-1 (12.9 +/- 2.5%) or IIA (19.8 +/- 7.4%). Thus, the secretion of TNF-alpha early in spinal cord injury may be involved in autoactivating microglia/macrophages. However, at the peak of microglial activation after injury, the activation state of microglia/macrophages is not stable and this process may still be reversible by blocking TNF-alpha

Towards a History of Mass Violence in the Etat Indépendant du Congo, 1885-1908

The present article provides an up-to-date scholarly introduction to mass violence in the Etat Indépendant du Congo (Congo Free State, EIC). Its aims are twofold: to offer a point of access to the extensive literature and historical debates on the subject, and to make the case for exchanging the currently prevalent top-down narrative, with its excessive focus on King Leopold's character and motives, for one which considers the EIC's culture of violence as a multicausal, broadly based and deeply engrained social phenomenon. The argument is divided into five sections. Following a general outline of the EIC's violent system of administration, I discuss its social and demographic impact (and the controversy which surrounds it) to bring out the need for more regionally focused and context sensitive studies. The dispute surrounding demographics demonstrates that what is fundamentally at stake is the place the EIC's extreme violence should occupy in the history of European ‘modernity’. Since approaches which hinge on Leopoldian exceptionalism are particularly unhelpful in clarifying this issue, I pause to reflect on how such approaches came to dominate the distinct historiographical traditions which emerged in Belgium and abroad before moving on to a more detailed exploration of a selection of causes underlying the EIC's violent nature. While state actors remain in the limelight, I shift the focus from the state as a singular, normative agent, towards the existence of an extremely violent society in which various individuals and social groups within and outside of the state apparatus committed violent acts for multiple reasons. As this argument is pitched at a high level of abstraction, I conclude with a discussion of available source material with which it can be further refined and updated

Managing hypertension in frail oldest-old-The role of guideline use by general practitioners from 29 countries.

The best management of hypertension in frail oldest-old (≥80 years of age) remains unclear and we still lack guidelines that provide specific recommendations. Our study aims to investigate guideline use in general practitioners (GPs) and to examine if guideline use relates to different decisions when managing hypertension in frail oldest-old. Cross-sectional study among currently active GPs from 29 countries using a case-vignettes survey. GPs participated in a survey with case-vignettes of frail oldest-olds varying in systolic blood pressure (SBP) levels and cardiovascular disease (CVD). GPs from 26 European countries and from Brazil, Israel and New Zealand were invited. We compared the percentage of GPs reporting using guidelines per country and further stratified on the most frequently mentioned guidelines. To adjust for patient characteristics (SBP, CVD and GPs' sex, years of experience, prevalence of oldest-old and location of their practice), we used a mixed-effects regression model accounting for clustering within countries. Overall, 2,543 GPs from 29 countries were included. 59.4% of them reported to use guidelines. Higher guideline use was found in female (p = 0.031) and less-experienced GPs (p<0.001). Across countries, we found a large variation in self-reported guideline use, ranging from 25% to 90% of the GPs, but there was no difference in hypertension treatment decisions in frail oldest-old patients between GPs that did not use and GPs that used guidelines, irrespective of the guidelines they used. Many GPs reported using guidelines to manage hypertension in frail oldest-old patients, however guideline users did not decide differently from non-users concerning hypertension treatment decisions. Instead of focusing on the fact if GPs use guidelines or not, we as a scientific community should put an emphasis on what guidelines suggest in frail and oldest-old patients