OBJECTIVES
Older people approaching end of life are commonly prescribed multiple medications, many of which may be inappropriate or futile. Our objective was to examine the effect of applying the ...STOPPFrail, a recently developed deprescribing tool, to the medication regimens of older patients with advanced frailty.
DESIGN
Randomized controlled trial.
SETTING
Two acute hospitals in Ireland.
PARTICIPANTS
Adults 75 years or older (n = 130) with advanced frailty and polypharmacy (five or more drugs), transferring to long‐term nursing home care.
INTERVENTION
A STOPPFrail‐guided deprescribing plan was presented to attending physicians who judged whether or not to implement recommended medication changes.
MEASUREMENTS
The primary outcome was the change in the number of regular medications at 3 months. Secondary outcomes included unscheduled hospital presentations, falls, quality of life, monthly medication costs, and mortality.
RESULTS
Intervention (n = 65) and control group (n = 65) participants were prescribed a mean (plus or minus standard deviation SD) of 11.5 (±3.0) and 10.9 (±3.5) medications, respectively, at baseline. The mean (SD) change in the number of medications at 3 months was −2.6 (±2.73) in the intervention group and −.36 (±2.60) in the control group (mean difference = 2.25 ± .54; 95% confidence interval CI = 1.18‐3.32; P < .001). The mean change in monthly medication cost was –$74.97 (±$148.32) in the intervention group and –$13.22 (±$110.40) in the control group (mean difference $61.74 ± $26.60; 95% CI = 8.95‐114.53; P = .02). No significant differences were found between groups for any of the other secondary outcomes.
CONCLUSION
STOPPFrail‐guided deprescribing significantly reduced polypharmacy and medication costs in frail older people. No significant differences between groups were observed with regard to falls, hospital presentations, quality of life, and mortality, although the trial was likely underpowered to detect differences in these outcomes. J Am Geriatr Soc 68:762–769, 2020
Polypharmacy and prescribing of potentially inappropriate medications (PIMs) are the key elements of inappropriate medication use (IMU) in older multimorbid people. IMU is associated with a range of ...negative healthcare consequences including adverse drug events and unplanned hospitalizations. Furthermore, prescribing guidelines are commonly derived from randomized controlled clinical trials which have specifically excluded older adults with multimorbidity. Consequently, indiscriminate application of single disease pharmacotherapy guidelines to older multimorbid patients can lead to increased risk of drug-drug interactions, drug-disease interactions and poor drug adherence. Both polypharmacy and PIMs are highly prevalent in older people and strategies to improve the quality and safety of prescribing, largely through avoidance of IMU, are needed. In the last 30 years, numerous explicit PIM criteria-based tools have been developed to assist physicians with medication management in clinically complex multimorbid older people. Very few of these PIM criteria sets have been tested as an intervention compared with standard pharmaceutical care in well-designed clinical trials. In this review, we describe the most widely used sets of explicit PIM criteria to address inappropriate polypharmacy with particular focus on STOPP/START criteria and FORTA criteria which have been associated with positive patient-related outcomes when used as interventions in recent randomized controlled trials.
Key summary points
Aim
To update and validate STOPP/START criteria for potentially inappropriate prescribing.
Findings
STOPP/START version 3 has been expanded and validated by an international ...European panel of experts in geriatric pharmacotherapy. Version 3, with 190 criteria, is significantly larger than version 2 (114 criteria), reflecting the expansion of the pharmacopeia and clinical trials evidence base relevant to older people since the publication of version 2.
Message
STOPP/START version 3 represents an updated explicit list of potentially inappropriate medications and potential prescribing omissions aimed at optimizing medication and minimizing adverse drug reactions and events during medication review in older people, particularly those with multimorbidity and polypharmacy.
Purpose
STOPP/START is a physiological systems-based explicit set of criteria that attempts to define the clinically important prescribing problems relating to potentially inappropriate medications (PIMs–STOPP criteria) and potential prescribing omissions (PPOs–START criteria). The previous two versions of STOPP/START criteria were published in 2008 and 2015. The present study describes the revised and updated third version of the criteria.
Methods
A detailed system-by-system review of the published literature from April 2014 to March 2022 was undertaken with the aim of including clinically important new explicit PIM and PPO criteria and removing any criteria considered to be no longer correct or outdated. A panel of 11 academic physicians with recognized expertise in geriatric pharmacotherapy from 8 European countries participated in a Delphi panel with the task of validating the draft criteria. The panel was presented with the draft new criteria using the SurveyMonkey® on-line platform in which panelists were asked to indicate their level of agreement on a five-point Likert scale.
Results
Two hundred and four evidence-based draft criteria (one hundred and forty-five STOPP criteria, fifty-nine START criteria) were presented to panelists for assessment using the Delphi validation method. Over the course of four rounds of Delphi validation, the panel achieved consensus on 133 STOPP criteria and 57 START criteria, i.e., 190 STOPP/START criteria in total representing a 66.7% increase in the number of criteria compared to STOPP/START version 2 published in 2015.
Conclusion
A fully revised and updated version of STOPP/START criteria has been validated by a European expert panel using the Delphi consensus process.
Understanding soil organic carbon (SOC) sequestration is important to develop strategies to increase the SOC stock and, thereby, offset some of the increases in atmospheric carbon dioxide. Although ...the capacity of soils to store SOC in a stable form is commonly attributed to the fine (clay + fine silt) fraction, the properties of the fine fraction that determine the SOC stabilization capacity are poorly known. The aim of this study was to develop an improved model to estimate the SOC stabilization capacity of Allophanic (Andisols) and non‐Allophanic topsoils (0–15 cm) and, as a case study, to apply the model to predict the sequestration potential of pastoral soils across New Zealand. A quantile (90th) regression model, based on the specific surface area and extractable aluminium (pyrophosphate) content of soils, provided the best prediction of the upper limit of fine fraction carbon (FFC) (i.e. the stabilization capacity), but with different coefficients for Allophanic and non‐Allophanic soils. The carbon (C) saturation deficit was estimated as the difference between the stabilization capacity of individual soils and their current C concentration. For long‐term pastures, the mean saturation deficit of Allophanic soils (20.3 mg C g−1) was greater than that of non‐Allophanic soils (16.3 mg C g−1). The saturation deficit of cropped soils was 1.14–1.89 times that of pasture soils. The sequestration potential of pasture soils ranged from 10 t C ha−1 (Ultic soils) to 42 t C ha−1 (Melanic soils). Although meeting the estimated national soil C sequestration potential (124 Mt C) is unrealistic, improved management practices targeted to those soils with the greatest sequestration potential could contribute significantly to off‐setting New Zealand's greenhouse gas emissions. As the first national‐scale estimate of SOC sequestration potential that encompasses both Allophanic and non‐Allophanic soils, this serves as an informative case study for the international community.
A quantile regression model was developed and used to estimate the soil C stabilization capacity and saturation deficit for a wide range of New Zealand pasture and cropping soils. The overall mean saturation deficit for these soils was 15.1 ± 0.8 mg C g−1 soil. Accounting for differences in bulk density and land area, the mean saturation deficit of each major soil Order was used to estimate a national C sequestration potential of 124 ± 37 Mt C.
Adverse drug reactions (ADRs) are frequent and represent a significant healthcare burden. ADRs are a potentially avoidable contributor to excess unscheduled hospital admissions, higher morbidity, ...mortality, and healthcare costs. The objective of this review is to examine the epidemiology of ADRs in older multimorbid adults and to explore strategies for ADR prevention. ADRs in this population are often linked to commonly prescribed medications, including anticoagulants, antiplatelet agents, insulin, and non-steroidal anti-inflammatory drugs, but ADRs and adverse drug events (ADEs) in fact encompass a much broader range of culprit drugs. Age-related factors such as changes in pharmacokinetics and pharmacodynamics, multimorbidity, polypharmacy, and frailty have been associated with ADR occurrences. Various strategies have been proposed to prevent ADRs in different clinical settings, such as structured routine medication review and the use of bespoke software applications to identify potentially inappropriate prescriptions and drug interactions. Although these approaches have demonstrated some improvement in the quality of prescribing, there is still a lack of consistent evidence regarding their effectiveness in preventing ADRs. The nuanced and often intricate complexities associated with older patients’ pharmacotherapy necessitate a comprehensive approach to attenuate the impact of ADRs within this growing section of most populations globally.
Particle size fraction (clay, silt, and sand) is an important characteristic that influences several soil functions. The laser-diffraction method (LDM) provides a fast and cost-effective measurement ...of particle size distribution, but the results usually differ from those obtained by the traditional sieve-pipette method (SPM). This difference can persist even when calibration is applied between the two methods. This partly relates to the different size ranges of particles measured by the two methods as a result of different operational principles, i.e., particle sedimentation according to Stokes’ Law vs. Mie theory for laser beam scattering. The objective of this study was to identify particle size ranges of LDM equivalent to those measured by SPM and evaluate whether new calibration models based on size range correction can be used to improve LDM-estimated particle size fractions, using 51 soil samples with various texture collected from five soil orders in New Zealand. Particle size distribution was determined using both LDM and SPM. Compared with SPM, original data from LDM underestimated the clay fraction (< 2 μm), overestimated the silt fraction (2–53 μm), but provided a good estimation of the sand fraction (53–2 000 μm). Results from three statistical indices, including Pearson's correlation coefficient, slope, and Lin's concordance correlation coefficient, showed that the size ranges of < 2 and 2–53 μm defined by SPM corresponded with the < 5 and 5–53 μm size ranges by LDM, respectively. Compared with the traditional calibration (based on the same particle size ranges), new calibration models (based on the corrected size ranges of these two methods) improved the estimation of clay and silt contents by LDM. Compared with soil-specific models (i.e., different models were developed for different soils), a universal model may be more parsimonious for estimating particle size fractions if the samples to be assessed represent multiple soil orders.
Water-extractable organic matter is regarded as readily available substrate for soil microbes. However, little is known about the influence of extraction temperature and duration on its biochemical ...composition. The effect of temperature (20 vs. 80 °C) and extraction duration (1–24 h) on the amounts of water-extractable organic C (WEOC), water-extractable organic N (WEON), carbohydrates, phenolics, ninhydrin-reactive organic N (NRON), and mineral N were evaluated using four agricultural soils from New Zealand and eastern Canada. More WEOC and WEON were extracted in hot than in cold water, and the same was found for all biochemical compounds tested. Biochemical components increased rapidly during the first 4 h of extraction at 80 °C, and at a slower rate thereafter. In contrast, at 20 °C, concentrations of all measured components were at or close to their maximum after 1 h and showed little change thereafter. Glucose and nitrate in the 20 °C extracts both declined substantially between 1 and 24 h, likely due to microbial activity. Moreover, the disappearance of glucose induced a decline in the ratio of carbohydrate-C to phenolic-C. The carbohydrates measured in water extracts at both temperatures were predominantly of microbial origin after 1 h. However, the proportion of microbial carbohydrates gradually declined and the proportion of plant carbohydrates increased from 1 to 24 h at 80 °C. Based on these findings, we recommend limiting extractions to 1 h or less at 20 °C and to 4 h or less at 80 °C to minimize compositional changes that may occur during longer extraction periods.
•Water-extractable organic matter was obtained for soils from different countries.•All WEOM constituents were easily detectable after 1 h at 20 °C and 4 h at 80 °C.•Glucose and nitrate concentrations decreased at extraction times >1 h at 20 °C.•Carbohydrate profile changed with extraction time >4 h at 80 °C.•It is recommended to limit extraction time to ≤1 h at 20 °C and ≤4 h at 80 °C.
As soils under permanent pasture and grasslands have large topsoil carbon (C) stocks, the scope to sequester additional C may be limited. However, because C in pasture/grassland soils declines with ...depth, there may be potential to sequester additional C in the subsoil. Data from 247 continuous pasture sites in New Zealand (representing five major soil Orders and ~80% of the grassland area) showed that, on average, the 0.15–0.30 m layer contained 25–34 t ha−1 less C than the top 0.15 m. High‐production grazed pastures require periodic renewal (re‐seeding) every 7–14 years to maintain productivity. Our objective was to assess whether a one‐time pasture renewal, involving full inversion tillage (FIT) to a depth of 0.30 m, has potential to increase C storage by burying C‐rich topsoil and bringing low‐C subsoil to the surface where C inputs from pasture production are greatest. Data from the 247 pasture sites were used to model changes in C stocks following FIT pasture renewal by predicting (1) the C accumulation in the new 0–0.15 m layer and (2) the decomposition of buried‐C in the new 0.15–0.30 m layer. In the 20 years following FIT pasture renewal, soil C was predicted to increase by an average of 7.3–10.3 (Sedimentary soils) and 9.6–12.7 t C ha−1 (Allophanic soils), depending on the assumptions applied. Adoption of FIT for pasture renewal across all suitable soils (2.0–2.6 M ha) in New Zealand was predicted to sequester ~20–36 Mt C, sufficient to offset 9.6–17.5% of the country's cumulative greenhouse gas emissions from agriculture over 20 years at the current rate of emissions. Given that grasslands account for ~70% of global agricultural land, FIT renewal of pastures or grassland could offer a significant opportunity to sequester soil C and offset greenhouse gas emissions.
Soil organic C (SOC) stocks in permanent pastures and grasslands tend to be strongly stratified, being high near the surface and declining with depth. A one‐time use of full inversion tillage during pasture renewal (FIT‐PR) could increase SOC storage by burying C‐rich topsoil and bringing low‐C subsoil to the surface where C inputs from pasture are greatest. Data from New Zealand permanent pasture soils indicate the potential for FIT‐PR to increase average SOC stocks (over 20 years) in allophanic (9.6–12.7 t C ha−1) and sedimentary (7.3–10.3 t C ha−1) soils, with the amount sequestered related to pre‐renewal SOC stratification ratio.
There is a well-recognized need for improved fractionation methods to partition soil organic matter into functional pools. Physical separation based on particle size is widely used, yielding ...particulate organic matter (POM, i.e., free or “uncomplexed” organic matter > 50 μm) as the most labile fraction. To evaluate whether POM meets criteria for an ideal model pool, we examined whether it is: 1) unique, i.e., found only in the > 50 μm fraction and 2) homogeneous, rather than a composite of different subfractions. Following ultrasonic dispersion, sand (> 50 μm) along with coarse (20–50 μm) and fine (5–20 μm) silt fractions were isolated from a silt loam soil under long-term pasture at Lincoln, New Zealand. The sand and silt fractions contained 20% and 21% of total soil C, respectively. We adopted a sequential density separation procedure using sodium polytungstate with density increasing step-wise from 1.7 to 2.4 g cm−3 to recover organic matter (light fractions) from the sand and silt fractions. Almost all (ca. 90%) the organic matter in the sand fraction and a large proportion (ca. 60%–70%) in the silt fractions was recovered by sequential density separation. The results suggested that POM is a composite of organo-mineral complexes with varying proportions of organic and mineral materials. Part of the organic matter associated with the silt fractions shared features in common with POM. In a laboratory bio-assay, biodegradability of POM varied depending on land use (pasture > arable cropping). We concluded that POM is neither homogeneous nor unique.
Rapid and transient changes in pH frequently occur in soil, impacting dissolved organic matter (DOM) and other chemical attributes such as redox and oxygen conditions. Although we have detailed ...knowledge on microbial adaptation to long-term pH changes, little is known about the response of soil microbial communities to rapid pH change, nor how excess DOM might affect key aspects of microbial N processing. We used potassium hydroxide (KOH) to induce a range of soil pH changes likely to be observed after livestock urine or urea fertilizer application to soil. We also focus on nitrate reductive processes by incubating microcosms under anaerobic conditions for up to 48 h. Soil pH was elevated from 4.7 to 6.7, 8.3 or 8.8, and up to 240-fold higher DOM was mobilized by KOH compared to the controls. This increased microbial metabolism but there was no correlation between DOM concentrations and CO
respiration nor N-metabolism rates. Microbial communities became dominated by
bacteria within 16 h, while few changes were observed in the fungal communities. Changes in N-biogeochemistry were rapid and denitrification enzyme activity (DEA) increased up to 25-fold with the highest rates occurring in microcosms at pH 8.3 that had been incubated for 24-hour prior to measuring DEA. Nitrous oxide reductase was inactive in the pH 4.7 controls but at pH 8.3 the reduction rates exceeded 3,000 ng N
-N g
h
in the presence of native DOM. Evidence for dissimilatory nitrate reduction to ammonium and/or organic matter mineralisation was observed with ammonium increasing to concentrations up to 10 times the original native soil concentrations while significant concentrations of nitrate were utilised. Pure isolates from the microcosms were dominated by
spp. and exhibited varying nitrate reductive potential.
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