Patients are willing to discuss the option of continuing PPI use or trying to reduce their PPI; however, a range of attitudes exist. The results suggest that reducing a PPI is a preference-sensitive decision. Therefore, patient attitudes should be elicited and incorporated into shared decision making surrounding the decision to continue or try deprescribing a PPI, and structured tools will be helpful to encourage this.

The haptophyte Prymnesium parvum forms harmful blooms toxic to fish in coastal and inland waters. Its growth in relation to niche factors is poorly characterized for the low salinities found in the inland waters in which P. parvum blooms have occurred. The specific growth rate of P. parvum as a function of temperature and salinity was determined in nutrient-sufficient cultures with low salinity. Additionally, phosphorus-limited growth was determined at low salinity and temperatures at or below 20uC. In nutrient-sufficient cultures, decreasing salinity from 4 g L 21 to 0.5 g L 21 reduced the growth rate of P. parvum. The estimated optimal temperature for growth decreased with decreasing salinity from about 27uC at salinities above 10 g L 21 , to about 24uC at 4 g L 21 , to about 22uC at 0.5 g L 21 . In phosphorus-limited experiments, the half-saturation concentration for growth was less than 0.02 mmol L 21 under most conditions. The phosphorus-saturated growth rate was 0.84 d 21 at 4 g L 21 salinity and 20uC, and it was reduced at lower salinities and temperatures. The salinity-temperature interaction found here weakens the negative effect of low temperature on growth at low salinity and might partially explain why blooms of P. parvum occur in the winter months in inland waters of the southwestern United States. However, the relatively slow growth of P. parvum at low temperature and salinity suggests that additional factors should be examined, such as reduced effects of competitors, pathogens, and grazers during winter.

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IntroductionIndividualizing glycemic targets to goals of care and time to benefit in persons with type 2 diabetes is good practice, particularly in populations at risk of hypoglycemia and adverse outcomes relating to the use of antihyperglycemics. Guidelines acknowledge the need for relaxed targets in frail older adults, but there is little guidance on how to safely deprescribe (i.e. stop, reduce or substitute) antihyperglycemics.MethodsThe purpose of this study was to synthesize evidence from all studies evaluating the effects of deprescribing versus continuing antihyperglycemics in older adults with type 2 diabetes. To this end, we searched MEDLINE, EMBASE, and Cochrane Library (July 2015) for controlled studies evaluating the effects of deprescribing antihyperglycemics in adults with type 2 diabetes. All such studies were eligible for inclusion in our study, and two independent reviewers screened titles, abstracts and full-text articles, extracted data, and evaluated risk of bias. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment and a narrative summary were completed.ResultsWe identified two controlled before-and-after studies, both of very low quality. One study found that an educational intervention decreased glyburide use while not compromising glucose control. The other reported that cessation of antihyperglycemics in elderly nursing home patients resulted in a non-significant increase in glycated hemoglobin (HbA1C). No significant change in hypoglycemia rate was found in the only study with this outcome measure.ConclusionsThere is limited evidence available regarding deprescribing antihyperglycemic medications. Adequately powered, high-quality studies, particularly in the elderly and with clinically important outcomes, are required to support evidence-based decision-making.Protocol registration numberCRD42015017748.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-016-0220-9) contains supplementary material, which is available to authorized users.