Does missing data matter in the revised Patients' Attitudes Towards Deprescribing questionnaire? A systematic review and two case analyses.

BACKGROUND: The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire was developed to capture beliefs and perceptions of patients about deprescribing. In general, handling of missing data is underreported in survey studies. Underlying mechanisms related to missing data may impact the findings from survey studies. OBJECTIVES: The aim of this study was to assess the missing data in studies using the rPATD questionnaire through a systematic review and datasets from two studies. METHODS: First, this review updated a systematic review on the rPATD (and other versions). We searched Medline via OVID, EMBASE, Scopus, Web of Science until 31st January 2023. Missing data reporting and methods to handle them were collected. Second, data from two deprescribing studies were analyzed using three methods of missing data handling: complete case analysis, personal mean substitution, and multiple imputation. We compared the scores from each domain and the associations of the domains with two questions from the rPATD to highlight how using different methods can influence the interpretation of study findings. RESULTS: We identified 49 studies: 31 (63 %) from this study and 18 (37 %) from the original systematic review. The question or domain with the most missing data could be identified in 9 studies (18.4 %). Missing data management was reported in 19 studies (38.8 %). In one case analysis, the "Burden" domain was significantly associated with the question "I would like to try stopping one of my medicines to see how I feel without it" using complete case analysis (p = 0.044) or multiple imputation (p = 0.038), but not when using personal mean substitution (p = 0.057). CONCLUSIONS: Missing data and methods used to handle missing data were underreported in studies using the rPATD questionnaire. The methods should be chosen carefully as our analyses from two distinct studies suggest that they may impact the interpretation of the findings from the questionnaire.

Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review.

OBJECTIVES: Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. DESIGN: Systematic review of qualitative and mixed-methods studies. SETTING AND PARTICIPANTS: Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings. METHODS: Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW). RESULTS: We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints. CONCLUSIONS AND IMPLICATIONS: The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.

Use of deprescribing search filters in systematic review search strategies: A case study.

Two deprescribing search filters for MEDLINE and one deprescribing search filter for Embase have been recently developed, including objectively developed search filters. The objective of this case study was to implement these three deprescribing search filters in systematic review (SR) search strategies and to assess their effect on performances. SR that independently developed original search strategies (OSS) were selected. The deprescribing filters were implemented in each OSS, generating two implemented search strategies (ISS1 and ISS2) in MEDLINE and one ISS (ISS3) in Embase. OSS were re-run on the same date as ISS. The performances of ISS and OSS were calculated and compared. Two SR were included (SR1 and SR2). For MEDLINE, SR1 included 12 articles. The sensitivity was 50% for OSS, 58% for ISS1 and 42% for ISS2. SR2 included four articles. The sensitivity of OSS, ISS 1 and 2 was 25%. For Embase, SR1 included 12 articles. The sensitivity was 33% for OSS and 58% for ISS3. SR2 included four articles. None of the four included articles were retrieved with OSS or ISS3. While sensitivity of OSS was moderate, the objectively developed deprescribing filters maintained or slightly improved this sensitivity when implementing.

Development and validation of search filters to retrieve medication discontinuation articles in Medline and Embase.

BACKGROUND: Medication discontinuation studies explore the outcomes of stopping a medication compared to continuing it. Comprehensively identifying medication discontinuation articles in bibliographic databases remains challenging due to variability in terminology. OBJECTIVES: To develop and validate search filters to retrieve medication discontinuation articles in Medline and Embase. METHODS: We identified medication discontinuation articles in a convenience sample of systematic reviews. We used primary articles to create two reference sets for Medline and Embase, respectively. The reference sets were equally divided by randomization in development sets and validation sets. Terms relevant for discontinuation were identified by term frequency analysis in development sets and combined to develop two search filters that maximized relative recalls. The filters were validated against validation sets. Relative recalls were calculated with their 95% confidences intervals (95% CI). RESULTS: We included 316 articles for Medline and 407 articles for Embase, from 15 systematic reviews. The Medline optimized search filter combined 7 terms. The Embase optimized search filter combined 8 terms. The relative recalls were respectively 92% (95% CI: 87-96) and 91% (95% CI: 86-94). CONCLUSIONS: We developed two search filters for retrieving medication discontinuation articles in Medline and Embase. Further research is needed to estimate precision and specificity of the filters.

[Spinal injury related to alpine winter sports]. / Fractures de la colonne vertébrale lors d'accidents de ski ou autres sports de neige.

Winter sports are the cause of a significant number of spinal injuries in Switzerland. However, the number of patients, the mechanism, the presentation, the diagnosis and the treatment of vertebral fractures have considerably evolved over the last decades. As the hospital of Sion, in Valais, is particularly exposed to these diagnoses, we analyzed two series of prospective cases 30 years apart (1989-1990 and 2019-2020) and propose a review of the main types and mechanisms of fractures, diagnosis, and management for the primary care physician.

Les sports d'hiver sont à l'origine d'un nombre important de lésions de la colonne vertébrale en Suisse. Cependant, le nombre de patients, le mécanisme, la présentation, le diagnostic et le traitement des fractures vertébrales ont considérablement évolué au cours des dernières décennies. L'hôpital de Sion, en Valais, étant particulièrement exposé à ces diagnostics, nous avons analysé deux séries de cas prospectives à 30 ans d'intervalle (1989-1990 et 2019-2020) et proposons une revue des principaux types et mécanismes de fractures, diagnostics, et prises en charge pour le médecin de premier recours.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. METHODS: We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript. RESULTS: We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose. CONCLUSIONS: We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

The interdural hematoma: A subtype of convexity subdural/dural hematoma with specific radioanatomical characteristics.

Background: Rare cases of biconvex hematomas splitting the convexity dura mater were reported and denominated interdural hematoma (IDH). Due to their rarity, little is known about their radiological characteristics, and in most cases, their invasive management with craniotomy and dural membrane excision is unnecessary. Case Description: We report here a case of single burr-hole endoscopic evacuation of an IDH and its complete resolution after the 6-month follow-up imaging. The literature review reveals 11 reported cases of IDH. Most of them are male and the mean age is 65 years (range 51-90). Most of the reported IDHs were misdiagnosed as epidural hematoma or meningioma, and therefore, they have been managed invasively through craniotomy with dural excision. Diagnosis of the interdural nature was confirmed macroscopically during surgery in all cases and histology was reported for 6 cases. Image analysis found a double dural beak sign and biconvex shape on coronal planes, subarachnoid space enlargement at the collection extremities, and irregular thick inner wall as common radiological aspects of the IDH. Conclusion: IDH is a rarely reported and often misdiagnosed dural hematoma subtype. Its invasive treatment through craniotomy is likely related to its unknown radiological characteristics. We review and raise awareness about potentially unique radiological anatomy that could avoid unnecessary invasive treatment. Moreover, we report the first case of endoscopically evacuated IDH with long-term follow-up imaging showing complete resolution.

Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial.

Background: Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults. Methods: This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires. Discussion: This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways. Clinical trial registration: ClinicalTrials.gov, identifier, NCT05765656.

Visual Search Strategies of Elite Fencers: An Exploratory Study in Ecological Competitive Situation.

This study investigates the visual activity of fencers in conditions resembling official competitions. Previous research in experimental conditions has shown that experts focus on specific areas of the torso and the armed arm to control movement initiation. Eight right-handed fencers (epee: two males, one female; foil: one male; sabre: two males, two females) participated in a simulated competition, wearing an eye tracker during one bout. The findings showed that the main fixation in foil and sabre is the upper torso, while in epee, it is the lower torso. In epee and sabre, the upper torso is viewed about 50% of the time, with three other areas also observed, while in foil, the fixation is totally directed to the upper torso. Additionally, two new areas of interest were identified: the score machine and an area involving fixations other than the opponent. The study found no direct link between visual activity and performance. The visual search strategy varies among weapons, with foil using a gaze anchor or foveal spot and epee and sabre utilizing a visual pivot due to the discipline's inherent rules. The study also emphasizes that competition-like conditions can disrupt visual activity with external stimuli, possibly affecting performance.

Traumatic Brain Injury in Alpine Winter Sports: Comparison of Two Case Series from a Swiss Trauma Center 30 Years Apart.

BACKGROUND: Between 3 and 15% of winter sports-related injuries are related to head injuries, which are the primary cause of mortality and disability among skiers. Despite the widespread adoption of helmets in winter sports, which has reduced the incidence of direct head injury, there is a paradoxical trend of an increasing number of individuals wearing helmets sustaining diffuse axonal injuries (DAI), which can result in severe neurologic sequelae. METHODS: We retrospectively reviewed 100 cases collected by the senior author of this work from 13 full winter seasons during the period from 1981 to 1993 and compared them with 17 patients admitted during the more shortened 2019 to 2020 ski season due to COVID-19. All data analyzed come from a single institution. Population characteristics, mechanism of injury, helmet use, need for surgical treatment, diagnosis, and outcome were collected. Descriptive statistics were used to compare the two databases. RESULTS: From February 1981 to January 2020, most skiers with head injuries were men (76% for the 1981-1993 and 85% for 2020). The proportion of patients aged over 50 increased from <20% in 1981 to 65% in 2020 (p < 0.01), with a median age of 60 years (range: 22-83 years). Low- to medium-velocity injuries were identified in 76% (13) of cases during the 2019 to 2020 season against 38% (28/74) during the 1981 to 1993 seasons (p < 0.01). All injured patients during the 2020 season wore a helmet, whereas none of the patients between 1981 and 1993 wore one (p < 0.01). DAI was observed in six cases (35%) for the 2019 to 2020 season against nine cases (9%) for the 1981 to 1993 season (p < 0.01). Thirty-four percent (34) of patients during the 1981 to 1993 seasons and 18% (3) of patients during the 2019 to 2020 season suffered skeletal fractures (p = 0.02). Among the 100 patients of the 1981 to 1993 seasons, 13 (13%) died against 1 (6%) from the recent season during care at the hospital (p = 0.15). Neurosurgical intervention was performed in 30 (30%) and 2 (12%) patients for the 1981 to 1993 and 2019 to 2020 seasons, respectively (p = 0.003). Neuropsychological sequelae were reported in 17% (7/42) of patients from the 1981 to 1993 seasons and cognitive evaluation before discharge detected significant impairments in 24% (4/17) of the patients from the 2019 to 2020 season (p = 0.29). CONCLUSION: Helmet use among skiers sustaining head trauma has increased from none in the period from 1981 to 1993 to 100% during the 2019 to 2020 season, resulting in a reduction in the number of skull fractures and deaths. However, our observations suggest a marked shift in the type of intracranial injuries sustained, including a rise in the number of skiers experiencing DAI, sometimes with severe neurologic outcomes. The reasons for this paradoxical trend can only be speculated upon, leading to the question of whether the perceived benefits of helmet use in winter sports are actually misinterpreted.

Reducing the learning curve of interlaminar full-endoscopic discectomy: mushroom model-simulation training.

PURPOSE: To describe a cheap simulation model used to reduce the learning curve of the interlaminar full-endoscopic discectomy in a pilot study. INTRODUCTION: The steep and difficult learning curve remain one of the main obstacles against the widespread diffusion of interlaminar full endoscopic lumbar discectomy (ILFED). One solution to overcome this learning curve is training with deliberate practice. As realistic models are relatively expensive and cadaver workshops not readily available, we developed a simple and cheap model to train the key steps of the procedure. METHODS: A simple and cheap model were designed. It consists of a king oyster mushroom stalk, a glove finger, a sponge and cotton wool. In order to fix the model to the table and to simulate the level of the patient's skin whereupon the hand of the surgeon relies, a wooden holding device was also used. As the purpose of this pilot study was to evaluate the model as a stimulator, it was tested during an advanced endoscopic training course. RESULTS: A step-by-step learning method with key steps was used by participants attending an advanced ILFED training on expensive realistic models. The model was considered as comparable and enough realistic to train key steps in order to reduce the learning curve and training costs. CONCLUSION: We present an affordable, simple and reproducible training model, which allows for deliberate practice of the key steps of the ILFED procedure. The model may be used by surgeons starting with spinal endoscopy.

[Endoscopic lumbar surgery]. / Chirurgie lombaire endoscopique.

Spinal endoscopy is the result of an evolution of techniques and technologies in the service of an ever less invasive surgery. It allows the treatment of a large range of pathologies such as disc herniation or spinal stenosis and this range continues to increase. It has already proven its non-inferiority and cost-effectiveness compared to microsurgery despite a difficult learning curve. It has the potential to replace the microscopic «gold standard¼ as it allows a faster recovery for the patient and a shorter hospital stay.

L'endoscopie spinale est le résultat d'une évolution des techniques et des technologies au service d'une chirurgie toujours moins invasive. Elle permet de traiter un bon nombre de pathologies telles que la hernie discale ou la sténose canalaire et ce nombre continue d'augmenter. Elle a déjà prouvé sa non-infériorité et son rapport coûts-bénéfices avantageux par rapport à la microchirurgie, et ce, bien que sa courbe d'apprentissage ne soit pas toujours aisée. Elle a le potentiel de remplacer le « gold standard ¼ microscopique car elle permet une récupération plus rapide pour le patient et une hospitalisation plus courte.

Effects of Mindfulness for Performance Programme on Actual Performance in Ecological Sport Context: Two Studies in Basketball and Table Tennis.

Mindfulness For Performance is a programme that has been developed over 15 years. It aims to help athletes maintain effective attentional focus regardless of the disruptive sensations and thoughts induced by the performance situation. It is inspired by Mindfulness Based Stress Reduction and Acceptance Commitment Therapy programmes and has been adapted to the specificities of sport. It is composed of three steps: (a) psychoeducation and identification of the focus of attention, (b) mindfulness and acceptance training, and (c) integrating skills acquired into training and competition. This article reports the effects of MFP in two studies in national basketball players and in young table tennis players. The first study showed that mindfulness skills and free-throw accuracy during basketball games increased more in the experimental group than in the control group. Table tennis results revealed that participants who showed the highest percentage of adherence to the programme benefited more from MFP training in terms of performance outcome (i.e., accumulated points collected from published results compared with the baseline phase) than participants who showed weaker percentages of adherence to the programme. Both studies provided some evidence on the effects of MFP on specific performance indicators (i.e., free-throw accuracy in basketball and ranking points in table tennis), but this needs to be confirmed by further research measuring other relevant performance indicators. The impact and conditions of adherence also deserve more consideration.

Adaptation and Validation of the Arabic Version of the Mindfulness Inventory for Sport.

Our goal for this study was to adapt the Mindfulness Inventory for Sport (MIS) into written Arabic that would be easily understood in North African countries (Tunisia, Algeria and Morocco or TAM). Assessment tools in Arabic, such as this MIS-TAM version, are rare but essential for evaluating the effectiveness of sport psychology interventions. We adopted a committee approach to obtain a first Arabic version of the MIS. We asked a team of translators to adapt the items to the level of understanding of 13-year-old athletes by selecting words common to the culture of the three countries. The validation process underwent three phases. In Study 1, we tested MIS-TAM for clarity and deemed it acceptable. In Study 2 we tested the construct validity of two different models with confirmatory factorial analyses. These analyses confirmed that the structure of the 15-item MIS-TAM was psychometrically similar to the original version; it had a first order model encompassing three dimensions: Awareness, Non-Judgement and Refocusing. Analyses also found the internal consistency of the MIS-TAM acceptable. We assessed convergent validity in Study 3 with the Mindfulness Attention Awareness Scale, but no correlations between the two instruments were significant. In conclusion, the MIS-TAM has acceptable psychometric properties, though further work is needed regarding convergent validity. The rigorous work of translation and adaptation focused on shared linguistics in three target countries, and this questionnaire will also prove useful in other countries where Arabic is the main language.

Late metachronous cerebral metastasis of pancreatic adenocarcinoma of the tail of the pancreas: a case report.

BACKGROUND: Pancreatic cancer is one of the leading causes of cancer mortality and one of the most lethal malignant neoplasms worldwide. It is known for its local tumor extension to the liver; other common sites include the lung, distant lymph nodes, and bone. Brain metastases are extremely rare and represent less than 0.6% of all brain metastases. CASE REPORT: We report the case of a 66-year-old Caucasian female known to have adenocarcinoma of the tail of the pancreas treated with chemotherapy. During follow-up, thoracoabdominal computed tomography scans did not reveal any residual tumor or any metastasis. Moreover, tumor markers were within normal limits. She presented to the emergency department of our institution following an episode of a generalized tonic-clonic seizure 5 years following the initial diagnosis. Brain magnetic resonance imaging revealed an expansive left frontal intraaxial lesion compatible with high-grade glioma. The patient underwent surgical treatment. Histological examination revealed pancreatic metastasis. CONCLUSIONS: Thought to be rare, metachronous cerebral pancreatic metastasis should be kept in mind in patients with pancreatic cancer. Early diagnosis and complete surgical resection play a key role in the survival of these patients.

Development and validation of search filters to identify articles on deprescribing in Medline and Embase.

BACKGROUND: Deprescribing literature has been increasing rapidly. Our aim was to develop and validate search filters to identify articles on deprescribing in Medline via PubMed and in Embase via Embase.com . METHODS: Articles published from 2011 to 2020 in a core set of eight journals (covering fields of interest for deprescribing, such as geriatrics, pharmacology and primary care) formed a reference set. Each article was screened independently in duplicate and classified as relevant or non-relevant to deprescribing. Relevant terms were identified by term frequency analysis in a 70% subset of the reference set. Selected title and abstract terms, MeSH terms and Emtree terms were combined to develop two highly sensitive filters for Medline via Pubmed and Embase via Embase.com . The filters were validated against the remaining 30% of the reference set. Sensitivity, specificity and precision were calculated with their 95% confidence intervals (95% CI). RESULTS: A total of 23,741 articles were aggregated in the reference set, and 224 were classified as relevant to deprescribing. A total of 34 terms and 4 MeSH terms were identified to develop the Medline search filter. A total of 27 terms and 6 Emtree terms were identified to develop the Embase search filter. The sensitivity was 92% (95% CI: 83-97%) in Medline via Pubmed and 91% (95% CI: 82-96%) in Embase via Embase.com . CONCLUSIONS: These are the first deprescribing search filters that have been developed objectively and validated. These filters can be used in search strategies for future deprescribing reviews. Further prospective studies are needed to assess their effectiveness and efficiency when used in systematic reviews.

Field-mediated interactions of passive and conformation-active particles: multibody and retardation effects.

Particles in soft matter interact through the deformation field they create, as in the "cheerios" effect or the curvature-mediated interactions of membrane proteins. Using a simple model for field-mediated interactions between passive particles, or active particles that switch conformation randomly or synchronously, we derive generic results concerning multibody interactions, activity driven patterns, and retardation effects.

Effectiveness of a multi-faceted intervention to deprescribe proton pump inhibitors in primary care: protocol for a population-based, pragmatic, cluster-randomized controlled trial.

BACKGROUND: Inappropriately using proton pump inhibitors (PPI) is associated with severe adverse drug reactions and may have major consequences on healthcare costs. Deprescribing (the process by which a healthcare professional supervises the withdrawal of an inappropriate medication, to manage polypharmacy and improve outcomes) should be considered when an inappropriate PPI prescription is identified. Deprescribing interventions directed solely to prescribers have limited efficacy and are rarely targeted to patients. The aim of this trial is to assess the efficacy of a multi-faceted intervention with patients and general practitioners (GPs) to deprescribe PPI. METHODS: We will conduct a pragmatic, cluster-randomized, population-based, controlled trial in two regions of Western France. GPs with practices with over 100 patients, and their adult patient to whom over 300 defined daily doses (DDD) of PPIs have been dispensed in the year before baseline will be included. A total of 1300 GPs and 33,000 patients will be cluster-randomized by GPs practices. Three arms will be compared: i) a multi-faceted intervention associating a) a patient education brochure about PPI deprescribing sent directly to patients (the brochure was designed using a mixed-methods study), and b) a personalized letter with the Bruyere's PPI deprescribing algorithm sent to their respective GPs, or ii) a single intervention where only the GPs received the letter and algorithm, or iii) no intervention. The primary outcome will be PPI deprescribing, defined as the proportion of patients achieving at least a 50% decrease in the amount of PPI dispensed to them (DDD/year) at 12 months compared to baseline. Secondary outcomes will include incremental cost-utility ratio (using EQ-5D-5L scale and National Health Insurance's database), acid rebound (using the Gastroesophageal Reflux Disease Impact Scale), and the patients' attitudes towards deprescribing (using the French rPATD). DISCUSSION: Based on previous trials, we anticipate more than 10% "successful PPI deprescribing" in the multi-faceted intervention compared to the single intervention on GPs and the control arm. The study has been funded through a national grant and will be launched in autumn 2020, for early results by the end of 2022. TRIAL REGISTRATION: Clinicaltrials.gov NCT04255823 ; first registered on February 5, 2020.

Development of Patient Education Material for Proton Pump Inhibitor Deprescribing: A Mixed-Methods Study.

BACKGROUND: Proton pump inhibitor (PPI) deprescribing is recommended in case of inappropriate use. Patient education materials are key elements in the deprescribing process. OBJECTIVE: The study objective was to develop patient education material for PPI deprescribing in primary care in France. METHODS: This was a mixed-methods study involving (1) a literature review of the existing patient education materials on PPI deprescribing to identify key points to optimize the layout and content of the document; (2) development of a first version of the brochure by a pluri-professional steering group, following the national reference methodology of the French National Authority for Health (Haute Autorité de Santé) and iterative modifications of the patient brochure; (3) assessment of the content and understandability of the brochure by questionnaires followed by semistructured interviews with target patients; and (4) iterative brochure readability assessment with the Flesch reading ease tool. RESULTS: The final patient education material is a double-sided A3 brochure-that is, 4 A4 pages. The first round of user testing by questionnaire (n = 14 patients) led to modifications to improve the document understandability, validated in the second round of user testing by questionnaire (n = 10 patients). The semistructured interviews (n = 10 patients) highlighted an adequate comprehension, whereas actionability required some minor modifications. The readability test score of the final education brochure was 59.4. CONCLUSION AND RELEVANCE: This patient education brochure for PPI deprescribing is targeted to patients in primary care. Its impact on PPI deprescribing will be assessed in a population-based pragmatic trial in primary care.

Life goal reconstruction for people with chronic health conditions: Feasibility of a brief internet-based writing intervention using a minimally monitored delivery.

Examination of people's narratives after significant life changes revealed that engaging in current and future goal reconstruction was associated with higher levels of well-being while a failure to disengage from "what might have been" was associated with lower levels of well-being. This work led to the development of a life goal writing intervention that has received empirical support with most studies conducted among nonclinical populations. This study aims to assess the feasibility of a brief and minimally monitored internet-delivered writing therapy developed to facilitate life goal reconstruction among adults diagnosed with various chronic health conditions. Sixteen adults showing mild to moderate levels of anxiety or depression were recruited and a single group pretest/post-test design used. The 5-week program is comprised of psychoeducation, five weekly 30-min writing sessions, automated emails and symptom monitoring. Feasibility outcome measures included attrition, treatment adherence, acceptability and preliminary effectiveness. Primary outcome measures were The Patient Health Questionnaire -9 (PHQ-9) and the Generalized Anxiety Disorder -7 (GAD-7). Attrition was low (12%) and adherence high (93%). All but one study completer reported they would recommend the program. Mixed effects models revealed a significant and large reduction from pre-treatment to post-treatment on the PHQ-9 and GAD-7 and remission rates of 67% and 64% respectively. These findings suggest that it would be feasible to proceed to a larger trial. The brief duration of the intervention combined to a minimally monitored delivery may lend itself to implementation in routine clinical care milieus such as hospital settings.