• Objective: To review the adverse drug events (ADEs) risk of polypharmacy; the process of deprescribing and evidence of efficacy in reducing inappropriate polypharmacy; the enablers and barriers to deprescribing; and patient and system of care level strategies that can be employed to enhance deprescribing. • Methods: Literature review. • Results: Inappropriate polypharmacy, especially in older people, imposes a significant burden of ADEs, ill health, disability, hospitalization and even death. The single most important predictor of inappropriate prescribing and risk of ADEs in older patients is the number of prescribed medicines. Deprescribing is the process of systematically reviewing, identifying, and discontinuing potentially inappropriate medicines (PIMs), aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies, and deprescribing protocols have been developed and validated for clinical use. Barriers and enablers to deprescribing by individual prescribers center on 4 themes: (1) raising awareness of the prevalence and characteristics of PIMs; (2) overcoming clinical inertia whereby discontinuing medicines is seen as being a low value proposition compared to maintaining the status quo; (3) increasing skills and competence (self-efficacy) in deprescribing; and (4) countering external and logistical factors that impede the process. • Conclusion: In optimizing the scale and effects of deprescribing in clinical practice, strategies that promote depresribing will need to be applied at both the level of individual patient-prescriber encounters and systems of care.
The population is aging, with frailty emerging as a significant risk factor for poor outcomes for older people who become acutely ill. We describe the development and implementation of the Frail Older Persons’ Collaborative Program, which aims to optimise the care of frail older adults across healthcare systems in Queensland. Priority areas were identified at a co-design workshop involving key stakeholders, including consumers, multidisciplinary clinicians, senior Queensland Health staff and representatives from community providers and residential aged care facilities. Locally developed, evidence-based interventions were selected by workshop participants for each priority area: a Residential Aged Care Facility acute care Support Service (RaSS); improved early identification and management of frail older persons presenting to hospital emergency departments (GEDI); optimisation of inpatient care (Eat Walk Engage); and enhancement of advance care planning. These interventions have been implemented across metropolitan and regional areas, and their impact is currently being evaluated through process measures and system-level outcomes. In this narrative paper, we conceptualise the healthcare organisation as a complex adaptive system to explain some of the difficulties in achieving change within a diverse and dynamic healthcare environment. The Frail Older Persons’ Collaborative Program demonstrates that translating research into practice and effecting change can occur rapidly and at scale if clinician commitment, high-level leadership, and adequate resources are forthcoming.
Abstract Objective To explore medical trainees’ experiences and views concerning college-mandated research projects. Setting Online survey (Apr-Dec 2021) of current and recent past trainees of Australian and New Zealand colleges recruited through 11 principal colleges and snowballing. Participants Current trainee or completed training in the past 5 years. Main outcome measures We asked participants: whether they were required to conduct research as part of their college training, how they conducted their research, and their research activity after training. Respondents were invited to submit project reports for reporting and methodological quality evaluation. Data were analysed descriptively. Results Of the 372 respondents, 313 (86%) were required to complete one or more projects. Of the 177 who had completed their project (representing 267 projects), 76 provided information on 92 studies, with 34 reports submitted for evaluation. Most respondents developed their own research questions, study design and protocol, and conducted research in their own time, with 56% (38/68) stating they had the skills to complete their project. Most project teams consisted of their own medical specialty followed by statisticians, but seldom others. 44% (30/68) were satisfied with their research experience, and 53% (36/67) supported mandatory projects. Half (87/174) felt research was important for career development, 72% (44/61) considered initiating research post-training, and 54% (33/61) participated in it. Commonly expressed themes were time-burden of conducting projects, production of research waste, and the importance of research for skills development. Of the 34 submitted reports, 75% were published and 82% had a clear research question. Only three had a low risk of bias. Conclusion Majority of respondents conducted projects, but few shared details or reports. Despite valuing their research experiences and seeing clinical relevance, time conflicts and research waste were common concerns. Colleges should focus on enhanced research methods training and creating trainee research collaboratives. Protocol registration https://doi.org/10.17605/OSF.IO/BNGZK Summary box Majority of medical specialty trainees are required to conduct a research project to develop their research skills. We found the learning experiences are inconsistent, and the quality of research produced even more so. A new approach is required that is tailored to the research skills required by most practicing clinicians, namely being expert in applying research to practice and in participating in collaborative research. Those wishing to become leaders in research should be supported to do so via a specialised well-supported pathway.
This book illuminates the personal experience of being at the centre of a media scandal. The existential level of that experience is highlighted by means of the application of ethnological and phenomenological perspectives to extensive empirical material drawn from a Swedish context. The questions raised and answered in this book include the following: How does the experience of being the protagonist in a media scandal affect a person's everyday life? What happens to routines, trust, and self-confidence? How does it change the basic settings of his or her lifeworld?The analysis also contributes new perspectives on the fusion between interpersonal communication that takes place face to face, such as gossip and rumours, and traditional news media in the course of a scandal. A scandal derives its momentum from the audiences, whose engagement in the moral story determines its dissemination and duration. The nature of that engagement also affects the protagonist in specific ways. Members of the public participate through traditional oral communication, one vital aspect of which is activity in digital, social forums. The author argues that gossip and rumour must be included in the idea of the media system if we are to be able to understand the formation and power of a media scandal, a contention which entails critiques of earlier research. Oral interpersonal communication does not disappear when new communication possibilities arise. Indeed, it may be invigorated by them. The term news legend is introduced, to capture the entanglement between traditional news-media storytelling and oral narrative.
Physicians are expected to practice scientifically sound medicine, to be critical of industry claims, and to be immune from making clinical decisions biased by commercial sponsorship and marketing. The reality, as argued in this article, is that much of medical research, in its conduct and reporting, is distorted by commercial interests and that physician decision-making remains vulnerable to the effects of subliminal commercial promotion which has the potential to create conflicts of interest, or perceptions thereof, and undermine public trust. Research is presented that may encourage physicians to view recently revised Royal Australasian College of Physicians (RACP) guidelines on the ethical relationships between the medical profession and industry as an attempt to deal with such conflicts in protecting our authority and standing within the community.
Abstract We studied the mating system of the southern water skink, Eulamprus heatwolei , during spring and summer (encompassing the breeding season) in a population in southeastern Australia. We examined potential attributes that might influence the mating system and male reproductive success including home range size, physical proximity of adults and body size, and then genotyped all mothers, offspring and potential sires. Home range overlap of both sexes was extensive, with adult females sharing the greatest amount of space with each other and adult males the least amount of space with each other. However, not all adults hold home ranges. We classified approximately one quarter of adult males as home range holders and the rest as ‘floaters’. Adult females occupy home ranges more than males, with approximately three‐quarters classified as home range holders. Home range ownership is not correlated with body size for either sex, however, male body size is positively correlated with the number of adult female home ranges that his home range overlaps and adult male home ranges are larger than those of females. We used microsatellite genotyping to assign paternities to 55 offspring from 17 litters and then compared this data with our home range and behavioural observations. This species displays extreme levels of multiple paternity given the small mean clutch size of three. Multiple paternity was confirmed in 11 (64.7%) of 17 clutches but three other clutches (for a total of 82.4%) also may display multiple paternity. A total of 30 offspring from 12 litters were assigned to 10 of the 32 genotyped adult males from our study site. Of these 10 adult males, half were home range holders. Five complete clutches and a total of 25 out of the 55 offspring could not be positively assigned to any male surveyed as part of the study and were attributed to floater males or resident males adjacent to our study site that had not been genotyped. While sample sizes are small, neither male home range ownership nor body size is significantly correlated with the number of paternities a male obtained. Our study suggests a polygynous mating system for this species.
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