Search

Background: Deprescribing is an important intervention across different settings in medicine, but the literature supporting such a practice is still conflicting. Therefore, we aimed to capture the breadth of outcomes reported and assess the strength of evidence of the use of deprescribing for health outcomes., Methods: Umbrella review of systematic reviews of the use of deprescribing searching in Medline, Scopus, and Web of Science until 01 November 2023. The grading of evidence was carried out using the GRADE for intervention studies, whilst data regarding systematic reviews were reported as narrative findings., Results: Among 456 papers, 12 systematic reviews (six with meta-analysis) for a total of 231 RCTs and 44,193 patients were included. In any setting, deprescribing was able to significantly reduce the number of total and of potentially inappropriate medications (PIMs) in older patients (low certainty of evidence) and to reduce the proportion of participants potentially having several or PIMs (moderate certainty of evidence). In community, supported by a high certainty of evidence, deprescribing was not more effective than standard care in decreasing injurious falls, any falls or number of fallers. In nursing home, deprescribing was associated with a significantly lower PIMs than standard care (very low certainty of evidence). In end-of-life situations, deprescribing significantly reduced mortality rate of approximately 41% (high certainty of evidence)., Conclusions: Deprescribing is a promising intervention across different settings and situations, but a notable gap in the literature concerning its effects on substantial outcomes still exists., Competing Interests: Declaration of Competing Interest none., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The conversion of natural habitats to farmland is a major cause of biodiversity loss and poses the greatest extinction risk to birds worldwide. Tropical raptors are of particular concern, being relatively slow-breeding apex predators and scavengers, whose disappearance can trigger extensive cascading effects. Many of Africa's raptors are at considerable risk from habitat conversion, prey-base depletion and persecution, driven principally by human population expansion. Here we describe multiregional trends among 42 African raptor species, 88% of which have declined over a ca. 20-40-yr period, with 69% exceeding the International Union for Conservation of Nature criteria classifying species at risk of extinction. Large raptors had experienced significantly steeper declines than smaller species, and this disparity was more pronounced on unprotected land. Declines were greater in West Africa than elsewhere, and more than twice as severe outside of protected areas (PAs) than within. Worryingly, species suffering the steepest declines had become significantly more dependent on PAs, demonstrating the importance of expanding conservation areas to cover 30% of land by 2030-a key target agreed at the UN Convention on Biological Diversity COP15. Our findings also highlight the significance of a recent African-led proposal to strengthen PA management-initiatives considered fundamental to safeguarding global biodiversity, ecosystem functioning and climate resilience., (© 2024. The Author(s).)

Objectives: The purpose of this study was to assess the impact of medication reconciliation in the clinical practice from a hospital pharmacist point of view., Methods: A survey of the medication taken by cancer patients was performed on admission and on discharge in an oncological hospital, and then the subjects were followed up until discharge for 8 weeks. The pharmacist entered the data collected into a computer based tool which, by using Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP criteria) and Micromedex™ interactions database, automatically produces a report indicating the possible inconsistencies. The report is to check all potentially inappropriate prescriptions (PIPs) correlated to the drugs assumption by the patient. The appropriateness of the medication was scored using a Medication Appropriateness Index (MAI index) which was used to reconcile the medication list accordingly., Results: Patients reconciled at admission were 98, while patients reconciled at discharge were 90, 8 patients dropped out due to death. After the intervention of the hospital pharmacist, the average value of MAI index showed a significant reduction (3,391 to 2,552 p=0.039) and the median number of drugs prescribed per patient was decreased (7 vs 6; p=0.8058)., Conclusion: Our study demonstrated that the forms used in the reconciliation process, in particular the record card, is a promising method to increase the quality of the information related to drug use in clinical decisions. We think that medication reconciliation softwares should be widely used by health care professionals involved in the recording of drug history or prescription process.

Background: Potentially inappropriate prescriptions (PIPs), associated with adverse drug reactions, hospitalization, and wasteful healthcare spending, are common in elderly patients with comorbidities and multiple drugs., Objective: Our objective was to develop and validate a new tool to reduce PIPs in a hospitalized geriatric population., Methods: This was an observational cohort study of two cohorts (development [n = 100 subjects] and validation [n = 449 subjects]) of consecutive patients aged ≥65 years admitted to geriatric wards from April to December 2012. In the development phase, data on clinical and demographic characteristics, Multidimensional Prognostic Index (MPI), and prescribed drugs before hospital admission were collected and processed using a tool that integrates the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria and the Micromedex™ Drug-Reax System, a drug-management platform. This tool generated a report that was provided to the treating physicians. The weight of the PIPs, as defined by the Medication Appropriateness Index (MAI), was assessed on admission and on discharge. Similar procedures were followed in the validation cohort., Results: PIPs were independently associated with polypharmacy and with prescribing of antithrombotics, sedatives and antidepressants in both cohorts. The use of the tool led to a significant reduction of the MAI score, both in the development (median score 4 [interquartile range; IQR 1-5] vs. 2 [IQR 0-4], p < 0.001) and in the validation cohorts (median 3 [IQR 1-5] vs. 2 [IQR 0-4], p < 0.001)., Conclusion: This tool significantly reduced PIPs, as defined by the MAI score, in a hospitalized geriatric population. This strategy might be useful to minimize inappropriate medication exposure in this group.

Whether long-term use of vitamin K antagonists (VKAs) might affect the incidence of cancer is a longstanding hypothesis. We conducted a population-based study including all cancer- and thromboembolism-free patients of our health area; study groups were defined according to chronic anticoagulant use to VKA-exposed and control groups. Cancer incidence and cancer-related and overall mortality was assessed in both groups. 76 008 patients (3231 VKA-exposed and 72 777 control subjects) were followed-up for 8.2 (± 3.2) years. After adjusting for age, sex, and time-to-event, the hazard ratio of newly diagnosed cancer in the exposed group was 0.88 (95% confidence interval [95% CI] 0.80-0.98; P < .015). VKA-exposed patients were less likely to develop prostate cancer, 0.69 (95% CI 0.50-0.97; P = .008). The adjusted hazard ratio for cancer-related and overall mortality was 1.07 (95% CI 0.92-1.24) and 1.12 (95% CI 1.05-1.19), respectively. These results support the hypothesis that anticoagulation might have a protective effect on cancer development, especially prostate cancer.

Purpose: Many victims of accidental hypothermia are successfully resuscitated, but questions remain regarding the optimum rewarming techniques. Most of the invasive warming techniques such as closed thoracic lavage, hemodialysis, peritoneal dialysis, and cardiopulmonary bypass require specialized personnel, equipment, and procedures that are not readily available in all facilities. The objective of this study was to investigate the technical feasibility of utilizing a novel veno-veno rewarming circuit to resuscitate severely hypothermic subjects. If this alternative invasive warming technique is successful, it could be available to treat hypothermic patients in virtually any emergency department setting., Methods: The rewarming system consisted of a Baxter ThermaCyl warmer (Baxter Co., McGaw Park, IL), a roller pump, hemodialysis tubing, connectors, and 2 venous catheters. Blood was pumped from the body via the femoral vein, through the roller pump, into the warmer, and then returned to the body via the right jugular vein. Seven adult mongrel hounds of similar weights (20 to 25 kg) were anesthetized and instrumented for data collection. Temperature probes were placed in the rectum, the peritoneal cavity, and the esophagus to record core temperatures. Each animal was cooled by ice packing to a central core temperature of 29 degrees C and then rewarmed using the described veno-veno circuit. Vital signs, pulse oximetry, cardiac rhythm, and laboratory values were obtained prior to cooling the animals, and were repeated for every degree Celsius change once warming began. Christopher Haughn, MD, was the second place winner in the Basic Sciences Resident Competition at the Ohio American College of Surgeons meeting., Results: Because of technical difficulties, data from 1 dog were not included in the results. Of the remaining 6 dogs, all were rewarmed from 29 degrees C to 37 degrees C. Adverse side effects included gross hematuria, acidemia (median pH decrease was 0.088), and decreases in haptoglobin (median decrease 13.5 g/dl), hemoglobin (median decrease 1.35 g/dl), and arterial pO(2) level (median decrease 167 mm Hg). Decreases in blood pressure and heart rate were also noted during the cooling process, but reversed upon rewarming., Conclusions: From this pilot study, we conclude that our novel veno-veno circuit rewarming is a feasible method of rewarming hypothermic subjects and warrants further investigation and comparison with other active warming methods.

This study was undertaken to determine whether a prolongation of pharmaceutical antithrombotic prophylaxis beyond hospitalization for hip fracture is associated with a reduced mortality rate. One hundred seventy-nine cases with hip fracture (patients older than 50 years of age) admitted to local general hospitals in 1999 who received postdischarge prescription of any antithrombotic agent (heparin, oral anticoagulants, antiplatelet drugs) and 179 age- and sex-matched patients with hip fracture who did not were included. Postdischarge mortality was assessed at 90 days. Compared with patients who did not receive postdischarge prescription of antithrombotic agents, those who did had an odds ratio of 0.22 (95% confidence interval 0.08-0.59) for all causes of mortality. This result did not change after excluding nonvascular mortality (odds ratio, 0.17; confidence interval, 0.03-0.73; p=0.011). Patients admitted to the hospital for hip fracture are at high risk of death after discharge if they are not given antithrombotic treatment. To substantiate these data, ad hoc prospective randomized trials are needed.

Positive inotropic effects induced by 6-benzylaminopurine (6-BAP), kinetin and zeatin were studied in rat atria. The potency order observed was 6-BAP > or = kinetin > zeatin. Suramin, a P2-purinoceptor antagonist, inhibited the positive effect of 6-BAP suggesting the involvement of P2-purinoceptors in the positive effect of this cytokinin. In order to elucidate this point, 6-BAP was used against R-PIA (a P1-purinoceptor agonist) and ATP and UTP (both P2-purinoceptor agonists). 6-BAP did not influence negative inotropism by R-PIA whereas both nucleotides were inhibited after pretreatment with the cytokinin. LY 83583, an inhibitor of cGMP production, reduced the inotropic effect by cytokinin whereas L-NAME, an inhibitor of the L-arginine/nitric oxide pathway, did not influence the effect induced by 6-BAP. Indomethacin, an inhibitor of cyclooxygenase, and neomycin, an inhibitor of phospholipase C, did not significantly modify positive inotropism by 6-BAP. Verapamil, an inhibitor of L-type calcium channels, did not change the positive effect of 6-BAP while TMB-8 and dantrolene, two inhibitors of intracellular calcium release, reduced the increase of contractile tension induced by cytokinin. Our data on rat atria suggest that 6-BAP causes a positive inotropism through activation of P2-purinoceptors, involving modification of cGMP and of intracellular calcium.

A prospective, descriptive study is reported on the use and success of ultrasound-assisted internal jugular central vein catheterization (CVC) in the emergency department (ED). In patients not in cardiac arrest who had an indication for internal jugular CVC, lines were placed by trained ED staff using ultrasound. Data were collected prospectively on age, sex, body habitus, indication, vein visibility, number of punctures and needle passes, and success. There were 40 attempts at internal jugular CVC in 34 patients and ultrasound was used in 32 of the 40 (80%) attempts. Incidences of successful puncture and cannulation using ultrasound were 93.8% (30 of 32) and 81.3% (26 of 32), respectively, compared with 62.5% (5 of 8) and 62.5% (5 of 8) in the landmark group. In 8 patients with no visual or palpable landmarks, cannulation was successful in 100% (7 of 7) using ultrasound and in 0% (0 of 1) using landmark technique. Ultrasound-assisted internal jugular CVC is an easily learned technique that is useful in the ED. It may be especially helpful in patients in whom landmarks are not visible and not palpable.