Carolina J. P. W. Keijsers

Structured pharmaceutical analysis of the Systematic Tool to Reduce Inappropriate Prescribing is an effective method for final-year medical students to improve polypharmacy skills : a randomized controlled trial

Medical students may not be adequately trained to prescribe appropriately to older adults with polypharmacy. This study addressed how to teach students to minimize inappropriate polypharmacy. Final‐year medical students (N = 106) from two Dutch schools of medicine participated in this randomized controlled trial with a pre/posttest design. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) was used as the intervention. This medication review tool consists of five steps and is part of the Dutch multidisciplinary guideline on polypharmacy. Step two is a structured pharmaceutical analysis of drug use, assessed using six questions regarding undertreatment, ineffective treatment, overtreatment, potential adverse effects, contraindications or interactions, and dose adjustments. It is used in combination with the Screening Tool to Alert doctors to Right Treatment and the Screening Tool of Older Persons Prescriptions checklists. Students were asked to optimize the medication lists of real people, making use, or not, of the STRIP. The number of correct or potentially harmful decisions that the students made when revising the lists was determined by comparison with expert consensus. Students who used the STRIP had better scores than control students; they made more correct decisions (9.3 vs 7.0, 34%; P < .001, correlation coefficient (r) = 0.365) and fewer potentially harmful decisions (3.9 vs 5.6, −30%; P < .001, r = 0.386). E‐learning did not have a different effect from that of non‐E‐learning methods. Students were satisfied with the method. The STRIP method is effective in helping final‐year medical students improve their prescribing skills.

A comparison of medical and pharmacy students' knowledge and skills of pharmacology and pharmacotherapy

AIM Pharmacotherapy might be improved if future pharmacists and physicians receive a joint educational programme in pharmacology and pharmacotherapeutics. This study investigated whether there are differences in the pharmacology and pharmacotherapy knowledge and skills of pharmacy and medical students after their undergraduate training. Differences could serve as a starting point from which to develop joint interdisciplinary educational programmes for better prescribing. METHODS In a cross-sectional design, the knowledge and skills of advanced pharmacy and medical students were assessed, using a standardized test with three domains (basic pharmacology knowledge, clinical or applied pharmacology knowledge and pharmacotherapy skills) and eight subdomains (pharmacodynamics, pharmacokinetics, interactions and side-effects, Anatomical Therapeutic Chemical Classification groups, prescribing, prescribing for special groups, drug information, regulations and laws, prescription writing). RESULTS Four hundred and fifty-one medical and 151 pharmacy students were included between August 2010 and July 2012. The response rate was 81%. Pharmacy students had better knowledge of basic pharmacology than medical students (77.0% vs. 68.2% correct answers; P < 0.001, δ = 0.88), whereas medical students had better skills than pharmacy students in writing prescriptions (68.6% vs. 50.7%; P < 0.001, δ = 0.57). The two groups of students had similar knowledge of applied pharmacology (73.8% vs. 72.2%, P = 0.124, δ = 0.15). CONCLUSIONS Pharmacy students have better knowledge of basic pharmacology, but not of the application of pharmacology knowledge, than medical students, whereas medical students are better at writing prescriptions. Professional differences in knowledge and skills therefore might well stem from their undergraduate education. Knowledge of these differences could be harnessed to develop a joint interdisciplinary education for both students and professionals.

Pharmacists' and general practitioners' pharmacology knowledge and pharmacotherapy skills

Understanding differences in the pharmacology knowledge and pharmacotherapy skills of pharmacists and physicians is vital to optimizing interprofessional collaboration and education. This study investigated these differences and the potential influence of work experience. The pharmacology knowledge and pharmacotherapy skills of pharmacists, general practitioners (GPs), and trainees were compared, using a written assessment; 294 participants were included. Overall scores (mean ± SD) ranged from 69.3% ± 6.5% to 76.5% ± 9.5% for basic knowledge, 70.3% ± 10.8% to 79.7% ± 8.4% for applied knowledge, and 66.3% ± 21.1% to 84.7% ± 20.7% for pharmacotherapy skills (analysis of variance all P < .05). The pharmacists had the highest scores for all domains (P < .05), with the exception of pharmacist trainees, who had comparable scores for basic knowledge and pharmacotherapy skills (both P > .05). The GPs scored the lowest for pharmacotherapy skills (P < .05). More work experience was associated with better knowledge of applied pharmacology among pharmacists (by 2% per 10 work‐years), but with poorer pharmacotherapy skills among pharmacists and GPs (by 3% and 4% per 10 work‐years, respectively). In conclusion, pharmacists and GPs differ in their knowledge and skills, and these differences become more pronounced with more work experience. In general, pharmacists outperform pharmacist trainees, whereas GP trainees outperform GPs. These differences could be important for interdisciplinary collaboration and education.

Skin lesions after oral acetylcholinesterase inhibitor therapy: a case report.

and medical problems, more-severe and -complex deformities, poorer response to rehabilitation, greater need for postoperative medical assistance, and higher total cost of treatment, they present challenges for surgeons, so there is a tendency for family and doctors not to recommend even eligible patients for surgery. Nevertheless, with recent advances in the medical field, major surgical procedures such total hip arthroplasty (THA) and TKA can be safely in performed elderly adults. From the experience of this case and other similar cases in octogenarians (unpublished data), the advantages of performing SBTKA rather than the two-stage total knee arthroplasty include shorter exposure to anesthesia, less time in the hospital, shorter rehabilitation and physical therapy, fewer wound complications, less surgical stress, convenience for family members, and more cost-effective treatment. It has been observed that, after TKA, 76% of individuals aged 85 and older could live independently and approximately one-third could drive a car. Hence, the quality of improvement in their lives was significantly greater, and TKA seems a valuable procedure for them. Although SBTKA cannot add years to the lives of these individuals, it can add quality to the remaining years of their lives. When considering elderly adults for SBTKA, various factors such as age, overall health, mental function, and motivation must be considered. Older age alone should not discourage doctors and family from recommending surgery. These elderly adults, who live much longer than their counterparts, have exceptional qualities such as low probability of disease or disability, active engagement with life, and high cognitive and physical function.

Rating scales to measure side effects of antipsychotic medication: A systematic review

Introduction: Many patients experience side effects during treatment with antipsychotics. This article reviews the clinical use and psychometric characteristics of rating scales used to assess side effects in patients treated with antipsychotics. Methods: A systematic literature search was performed using the electronic databases PubMed and Embase, with predefined search terms. Results: In total, 52 different scales were used in the 440 articles retrieved. For multiple side effects measured with one scale, the Udvalg for Kliniske Undersøgelser Side Effects Rating Scale for Clinicians was used the most, whereas the Liverpool University Neuroleptic Side Effect Rating Scale had the best psychometric characteristics (Cronbach’s α 0.81 and test–retest reliability 0.89). The Simpson Angus Scale was used the most to rate extrapyramidal side effects, although the Maryland Psychiatric Research Center scale had the best characteristics (Cronbach’s α 0.80, test–retest reliability 0.92 and inter-rater reliability 0.81–0.90). The Arizona Sexual Experience Scale was used the most to assess sexual dysfunction, but the Antipsychotics and Sexual Functioning Questionnaire and the Nagoya Sexual Functioning Questionnaire had the best characteristics. Conclusion: This review will help researchers and clinicians make a purpose-oriented choice of which scale to use. Systematic review registration number: CRD42014013010.

A pharmacological approach to education

Health professionals need high quality education and training in pharmacology and pharmacotherapy. Deficiencies in knowledge and skills in prescribing medicines have been cited by junior doctors as a cause of error [1,2], and are likely to be important in causing prescribing errors and prescribing faults (defined as ‘irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing’) [3]. While it is clear that errors are multifactorial, better training should reduce preventable medication-related harm to patients and improve the quality of decision making [3]. The quantity of research in how best to undertake undergraduate education is rapidly increasing as the challenges of prescribing for new doctors are recognized, but there remains a dearth of good quality evidence about how to teach effectively. Specific evidence-based educational interventions are therefore hard to design [4]. However, well-known basic pharmacology parameters can be used as an analogy for pharmacology and pharmacotherapy education, and lessons can be drawn from the wider literature on education.

Antipsychotic drug use associated with urinary tract infections in older women

OBJECTIVES Antipsychotic drugs are frequently prescribed to elderly patients, but they are associated with serious adverse effects. The objective of the current study was to investigate the association between use of antipsychotics by elderly women and the risk of urinary tract infections (UTIs). COHORT STUDY SETTING Dispensing data were obtained from the PHARMO Database Network for the period 1998-2008. PARTICIPANTS Ambulatory Dutch women (≥65 years) with current and past use of antipsychotics. MEASUREMENTS Incidence rates of UTIs, as defined by use of nitrofurantoin, was calculated within and outside the period of exposure to antipsychotic drugs. Cox proportional hazard regression analysis with Andersen-Gill extension for recurrent events was used to calculate crude and adjusted hazard ratios (HRs). RESULTS During the study period, 18,541 women with a first prescription of an antipsychotic were identified. Current use of antipsychotics was associated with an increased risk of UTI compared to past use: HR, adjusted for age and history of UTIs, 1.33, 95% CI 1.27-1.39. A strong temporal relationship was found: the risk of being treated for a UTI was higher in the first week after the start of the treatment (adjusted HR 3.03, 95% CI 2.63-3.50) and decreased after 3 months (adjusted HR 1.22, 95% CI 1.17-1.28). Cumulative exposure was not associated with an increased risk of UTIs. There was no difference in effect between conventional and atypical antipsychotics. CONCLUSION Our results show an increased risk of uncomplicated UTIs during antipsychotic use in older female patients, especially in the first week of treatment.

Metoclopramide: A Safe Alternative to Domperidone? A Case Report on Severe Cardiac Adverse Effects in an Older Patient

Peripheral antidopaminergic medication is frequently prescribed to treat nausea. However, domperidone is ill-famed for its severe cardiac adverse effects. Metoclopramide has been suggested as a relatively safe alternative because it has long been considered to have less significant cardiovascular adverse effects. We present an older patient who developed severe bradycardia and hypotension shortly after receiving intravenous metoclopramide. Cardiac adverse effects of metoclopramide in elderly are not frequently described in the literature, especially not in patients without a major history of cardiac disease. We recommend caution with intravenous administered metoclopramide in older patients.

Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education

Prescribing is a core skill for junior doctors, yet 8–10% of their prescriptions contain errors. To ensure adequate training in prescribing, it is important to define the diseases for which junior doctors should be competent to prescribe. The aim of the present study was therefore to identify the essential diseases in prescribing for junior doctors.

Evaluating pharmacotherapy education: urgent need for hard outcomes

Recently, a call was made for more high-quality articles on clinical pharmacology and therapeutics (CPT) education [1]. Not only is there a lack of research in this field, but also the quality of the available literature is disturbing. Most of the evaluation methods currently used in undergraduate CPT education rely too heavily on ‘soft’ endpoints, such as satisfaction with the education received, and on intermediate endpoints, such as increase in knowledge and skills instead of improvement of patient care. Moreover, measures of knowledge and skills are often not valid, because selfassessment does not reflect actual knowledge and skills. Both issues are discussed in this letter. First, the lack of ‘hard endpoints’ is a problem. In educational research, it is common to classify endpoints on the basis of the four levels of evaluation described in Kirkpatrick’s model of impact of education (modified by Freeth) [2, 3] (Table 1). Unfortunately, studies of CPT education with hard endpoints (levels 3 & 4) are rare. For example, in four systematic reviews of undergraduate CPT education [4–7], only 2 of the 63 included articles (3%) used level 3 or 4 endpoints to evaluate their educational interventions (Table 1). In fact, most of the included articles (47; 75%) used level 2 endpoints, so-called intermediate endpoints. Improvement in intermediate endpoints (Kirkpatrick level 2) does not necessarily translate into improvement in patient care (Kirkpatrick level 4). Thus it is difficult to interpret the results of level 2 studies in terms of their value for CPT education. Secondly, the validity of the (soft) endpoints used in educational research is sometimes dubious. A recent study showed that self-reported confidence in prescribing skills is poorly correlated with assessed competence [8]. A logical consequence of this finding is that self-reported confidence should not be used as the primary measure of students’ prescribing skills at the undergraduate level. This prompted us to question whether the same is true for pharmacology and