Learning fluid prescription skills: why is it so challenging?

IIt is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011-12 at Queen's University Belfast were invited to participate during their 'Assistantship' placement in March 2012. Discussions in focus groups, consisting of between six and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Medical students and junior doctors find fluid prescription a challenging topic Results: Five prominent themes emerged: 'Teaching experience: a disruptive variation'; 'Curricular disconnections'; 'The driving test: Theory-practice transformation'; 'Role modelling: which standard to aspire to?'; and finally 'Reconciling the perceived risk'. Discussion: This re search provided insights into medical students' opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex andcontextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novicelearner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.

The relationship between BMI and the prescription of anti-obesity medication according to social factors: a population cross sectional study

Background: Obesity is a global public health problem. There are a range of treatments available with varying short and long term success rates. One option is the use of anti-obesity medication the prescription of which has increased dramatically in recent years. Despite this, little is known about the individual and GP practice factors that influence the prescription of anti-obesity medication. Methods: Multi-level logistic regression analysis was used to investigate factors associated with the prescription of anti-obesity medication in Northern Ireland using a population primary care prescribing database (~1.5 million people aged 16+ years) during 2009/10. Results: While 25.0% of people are obese, only 1.3% (2.1% of females, 0.6% of males) received anti-obesity medication. The relationship between medication rates and age differed by gender (P < 0.001) with prescriptions higher in younger females and older males. Prescribing of anti-obesity medication reflected obesity prevalence across urban/rural areas and deprivation. There was an unexplained two-fold difference, between the 25th and 75th percentile, in the GP practice prescription of anti-obesity medication. Conclusions: There is evidence of relative under-prescribing in males compared to females despite a similar prevalence of obesity. While the prevalence (and presumably the health consequences) of obesity worsens with age, younger females are more likely to be prescribed anti-obesity medication. This suggests an element of patient demand. Educational material to improve the understanding of the role of anti-obesity medication, for patients and practitioners, is recommended. But further study is needed to understand the factors responsible for the variation in prescribing between GP practices.

Prescription contraception use: a cross-sectional population study of psychosocial determinants

Objective: Many forms of contraception are available on prescription only for example, the oral contraceptive pill (OCP) and long-acting reversible contraceptives (LARCs). In this analysis we aim to identify key determinants of prescription contraceptive use.

Design: Cross-sectional population survey. Data on sociodemographic indices, concerns about the OCP and perceived barriers to access were collected.

Setting: Data set constructed from a representative population-based telephone survey of community dwelling adults in the Republic of Ireland (RoI)

Participants: 1515 women aged between 18 and 45 years

Main outcome measure: Self-reported user of the OCP or LARCs (intrauterine contraception, contraceptive injections or subdermal contraceptive implants) in the previous 12 months.

Results: For at least some of the previous year, 35% had used the OCP and 14% had used LARCs, while 3% had used two or more of these methods. OCP users were significantly younger, more likely to be unmarried and had higher income than non-users. Overall, 68% agreed with the statement ‘that taking a break from long-term use of the contraceptive pill is a good idea’ and 37% agreed with the statement that ‘the OCP has dangerous side effects’ and this was the strongest predictor variable of non-use of the OCP. Intrauterine contraception users were significantly older, more likely to be married and had lower income than non-users. Injections or subdermal contraceptive implant users were significantly younger, less likely to be married, had lower income and were less likely to agree that taking a break from long-term use of the pill is a good idea than non-users.

Conclusions: Prescription contraceptive use is sociodemographically patterned, with LARCs in particular being associated with lower incomes in the RoI. Concerns about the safety of the OCP remain prevalent and are important and modifiable determinants of contraceptive-related behaviour.

Exercise Prescription for Patients with Non-specific Chronic Low Back Pain: a Qualitative Exploration of Decision Making in Physiotherapy Practice

Background: Providing an effective exercise prescription process for patients with non-specific chronic low back pain (NSCLBP) is a challenging task. Emerging research has indicated that partnership in care and shared decision making are important for people with NSCLBP and calls for further investigation into the approaches used to prescribe exercise. Objective: To explore how shared decision making and patient partnership are addressed by physiotherapists in the process of exercise prescription for patients with NSCLBP. Design: A qualitative study using a philosophical hermeneutic approach. Methods: Eight physiotherapists were each observed on three occasions undertaking their usual clinical activities (total n=24 observations). They conducted brief interviews after each observation and a later in depth semi-structured interview. Iterative hermeneutic strategies were used to interpret the texts and identify the characteristics and processes of exercise prescription for patients with NSCLBP. Findings: The findings revealed how physiotherapy practice often resulted in unequal possibilities for patient participation which were in turn linked to the physiotherapists? assumptions about the patients, clinical orientation, cognitive and decision making processes. Three linked themes emerged: (1) I want them to exercise, (2) Which exercise? - the tension between evidence and everyday practice and (3) Compliance-orientated more than concordance based. Conclusions: This research, by focusing on a patient-centred approach, makes an important contribution to the body of evidence relating to the management of NSCLBP. It challenges physiotherapists to critically appraise their approaches to the prescription of exercise therapy in order to improve outcomes for these patients.

Effectiveness of three different walking prescription durations on total physical activity in normal- and overweight women.

OBJECTIVE: While there is a dose-response relationship between physical activity (PA) and health benefit, little is known about the effectiveness of different PA prescriptions on total daily PA. AIM: To test, under real-life conditions and using an objective, non-invasive measurement technique (accelerometry), the effect of prescribing additional physical activity (walking only) of different durations (30, 60 and 90 min/day) on compliance (to the activity prescribed) and compensation (to total daily PA). Participants in each group were prescribed 5 sessions of walking per week over 4 weeks. METHODS: 55 normal-weight and overweight women (mean BMI 25 ± 5 kg/m(2), height 165 ± 1 cm, weight 68 ± 2 kg and mean age 27 ± 1 years) were randomly assigned to 3 prescription groups: 30, 60 or 90 min/day PA. RESULTS: Walking duration resulted in an almost linear increase in the number of steps per day during the prescription period from an average of about 10,000 steps per day for the 30-min prescription to about 14,000 for the 90-min prescription. Compliance was excellent for the 30-min prescription but decreased significantly with 60-min and 90-min prescriptions. In parallel, degree of compensation subsequent to exercise increased progressively as length of prescription increased. CONCLUSION: A 30-min prescription of extra walking 5 times per week was well tolerated. However, in order to increase total PA further, much more than 60 min of walking may need to be prescribed in the majority of individuals. While total exercise 'volume' increased with prescriptions longer than 30 min, compliance to the prescription decreased and greater compensation was evident. © 2014 S. Karger GmbH, Freiburg.

Chronic kidney disease in type 2 diabetic patients followed-up by primary care physicians in Switzerland: prevalence and prescription of antidiabetic drugs.

QUESTION UNDER STUDY: The aim of this study was to assess the prevalence of chronic kidney disease (CKD) among type 2 diabetic patients in primary care settings in Switzerland, and to analyse the prescription of antidiabetic drugs in CKD according to the prevailing recommendations. METHODS: In this cross-sectional study, each participating physician was asked to introduce anonymously in a web database the data from up to 15 consecutive diabetic patients attending her/his office between December 2013 and June 2014. Demographic, clinical and biochemical data were analysed. CKD was classified with the KDIGO nomenclature based on estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio. RESULTS: A total of 1 359 patients (mean age 66.5 ± 12.4 years) were included by 109 primary care physicians. CKD stages 3a, 3b and 4 were present in 13.9%, 6.1%, and 2.4% of patients, respectively. Only 30.6% of patients had an entry for urinary albumin/creatinine ratio. Among them, 35.6% were in CKD stage A2, and 4.1% in stage A3. Despite prevailing limitations, metformin and sulfonylureas were prescribed in 53.9% and 16.5%, respectively, of patients with advanced CKD (eGFR <30 ml/min). More than a third of patients were on a dipeptidyl-peptidase-4 inhibitor across all CKD stages. Insulin use increased progressively from 26.8% in CKD stage 1-2 to 50% in stage 4. CONCLUSIONS: CKD is frequent in patients with type 2 diabetes attending Swiss primary care practices, with CKD stage 3 and 4 affecting 22.4% of cases. This emphasizes the importance of routine screening of diabetic nephropathy based on both eGFR and urinary albumin/creatinine ratio, the latter being largely underused by primary care physicians. A careful individual drug risk/benefit balance assessment is mandatory to avoid the frequently observed inappropriate prescription of antidiabetic drugs in CKD patients.

A. C. Thorburn Prescription Ledger

The gift plate in the front of the book indicates that the book is from Walker’s Drug Store, Niagara Falls, Ontario. Walker’s Drug Company was founded in 1925 by Ivan T. Walker. The dates of this book indicate that it is more likely to have come from A.C. Thorburn, Chemist and Druggist. A.C. Thorburn purchased Smith’s Pharmacy and Pursel and Company Dry Goods Store at the corner of Main Street and Lundy’s Lane in Niagara Falls, Ontario. In 1900, Pursel moved out and Thorburn’s Drug Store came into being. Ivan T. Walker, founder of Walker’s Drugs was employed by Thorburn Drugs in his teen years. The local doctors whose prescriptions are in the book include: J. H. McGarry; F.W.E. Wilson; C. F. Abraham; W.E. Olmsted; W.W. Thompson; Dr. Robb, dentist; Horace R. Elliot, physician and surgeon and Dr. Sutherland, eye, ear nose and throat specialist

Droit civil expliqué : de la prescription ou commentaire du titre XX du livre III du code Napoleón

UANL