Long-term effects of prescribed fire on mixed conifer forest structure in the Sierra Nevada, California

Treesearch

Phillip J. Van Mantgem; Nathan L. Stephenson; Eric Knapp; John Barrles; Jon E. Keeley

2011-01-01

The capacity of prescribed fire to restore forest conditions is often judged by changes in forest structure within a few years following burning. However, prescribed fire might have longer-term effects on forest structure, potentially changing treatment assessments. We examined annual changes in forest structure in five 1 ha old-growth plots immediately before...

Statistical Primer on Biosimilar Clinical Development.

PubMed

Isakov, Leah; Jin, Bo; Jacobs, Ira Allen

A biosimilar is highly similar to a licensed biological product and has no clinically meaningful differences between the biological product and the reference (originator) product in terms of safety, purity, and potency and is approved under specific regulatory approval processes. Because both the originator and the potential biosimilar are large and structurally complex proteins, biosimilars are not generic equivalents of the originator. Thus, the regulatory approach for a small-molecule generic is not appropriate for a potential biosimilar. As a result, different study designs and statistical approaches are used in the assessment of a potential biosimilar. This review covers concepts and terminology used in statistical analyses in the clinical development of biosimilars so that clinicians can understand how similarity is evaluated. This should allow the clinician to understand the statistical considerations in biosimilar clinical trials and make informed prescribing decisions when an approved biosimilar is available.

Impact of Secondary Prevention on Mortality after a First Ischemic Stroke in Puerto Rico.

PubMed

Rojas, Maria E; Marsh, Wallace; Felici-Giovanini, Marcos E; Rodríguez-Benitez, Rosa J; Zevallos, Juan C

2017-03-01

The objective of this study was to evaluate the impact of the prescription of secondary prevention therapies on mortality in Puerto Rican patients hospitalized with a first ischemic stroke. This was a retrospective secondary data analysis of the 2007 and 2009 Puerto Rico Stroke Registry electronic database. Information was obtained from the medical charts of patients discharged with ICD-9 codes 434 and 436 from 20 hospitals located in Puerto Rico. Descriptive analyses were conducted for demographics and comorbidities. Chi2 statistics compared the proportion of patients prescribed secondary prevention therapy and the proportion of patients not prescribed secondary prevention therapy. Lastly, survival rates were calculated from 2007 up to and including December 2010. The mean age of the 3,965 patients was 70 (±14) years. Secondary prevention therapy was prescribed to only 1% of the patients. The most frequent comorbidities were hypertension (85%), diabetes (52%), and hyperlipidemia (25%). The case fatality rate for patients prescribed secondary prevention therapy was 16%, compared to 26% for patients not prescribed secondary prevention therapy (p<0.01). The mean survival for stroke patients prescribed secondary preventions was 450 days (95% CI;182−718), compared to 266 days (95% CI; 244−287) for those not prescribed secondary prevention therapy (p = 0.175). A low percentage of patients with a first ischemic stroke were prescribed secondary prevention therapy. While not statistically significant, survival analysis suggests that secondary prevention therapy decreased mortality in patients with a stroke.

Comparison Between Self-Guided Langevin Dynamics and Molecular Dynamics Simulations for Structure Refinement of Protein Loop Conformations

DTIC Science & Technology

2011-01-01

SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT Same as Report (SAR) 18 . NUMBER OF PAGES 9 19a. NAME OF RESPONSIBLE PERSON a. REPORT...unclassified b. ABSTRACT unclassified c. THIS PAGE unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39- 18 sampling is based on...atom distance-scaled ideal-gas reference state (DFIRE-AA) statistical potential func- tion.[ 18 ] The third approach is the Rosetta all-atom energy func

Challenges in health visitor prescribing in a London primary care trust.

PubMed

Thurtle, Val

2007-11-01

In this primary care trust there was limited health visitor prescribing. A case study approach sought to identify reasons for this, to lead to recommendations and changes to develop health visitor prescribing. The situation was examined using qualitative methods to consider the opportunities and challenges in health visitor prescribing. Semi-structured interviews with eighteen health visitors and managers explored their views of health visitor prescribing and its position within the PCT. The findings demonstrated only three health visitors prescribed; yet the majority were positive about prescribing, both for clients and health visitor development. Practitioners recognised their difficult working context and felt that organisational systems were not supportive of prescribing. A culture of prescribing was not felt to be in evidence, but was seen as a realistic possibility. Recommendations for change focused on the organisation and practitioners, with improved communication and structures supportive of prescribing. There was a need for practitioners to be active in learning so that they could share knowledge, experience and commitment to prescribing in locally based groups.

Medication prescription: a pilot survey of Bernese doctors of chiropractic practicing in Switzerland.

PubMed

Wangler, Martin; Zaugg, Beatrice; Faigaux, Eric

2010-01-01

The purpose of this survey was to assess the use of and the attitude toward prescribing medication among doctors of chiropractic in 1 of 26 Swiss cantons. A Likert scale electronic questionnaire was sent to licensed doctors of chiropractic of the canton of Berne (n = 47). Percentages, mean values, and standard deviations were calculated. A follow-up survey was used to assess comments from the main survey. A probability value of P < .05 indicated a statistically significant difference. The response rate was 77%. Forty-one percent of the respondents stated that medications are a necessary component of the chiropractic treatment. Although 92% actively prescribe medication at least once a week, this is significantly less than asked for by their patients (P < .01). Seventy-two percent of the doctors of chiropractic rated the present privilege to prescribe nonprescription medications as an advantage for chiropractic care. Fifty-eight percent thought that chiropractic should aim at expanding the options of nonsteroidal anti-inflammatory drugs, analgesics, and muscle relaxants that can be prescribed. Ninety-one percent agreed on continuing education in pharmacology. Despite prescribing medication at least once a week, less than half of Bernese doctors of chiropractic perceived medications as a necessary component of their treatment, mainly using them to help patients who cannot sleep because of pain and to speed up recovery. When asked if they would be allowed to prescribe medications of the "B-list," the majority would want structured continuing education. Limited medication prescription was judged as an advantage for the chiropractic profession by this group of survey participants. Copyright 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.

14 CFR 19-2 - Maintenance of data.

Code of Federal Regulations, 2012 CFR

2012-01-01

... Operating Statistics Classifications Sec. 19-2 Maintenance of data. (a) Each air carrier required to file... in accordance with the uniform classifications prescribed. Codes are prescribed for each operating... flight numbers. The second grouping requires that the enplanement/deplanement information be broken out...

Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments.

PubMed

Okunseri, Christopher; Dionne, Raymond A; Gordon, Sharon M; Okunseri, Elaye; Szabo, Aniko

2015-11-01

Opioid analgesics prescribed for nontraumatic dental conditions (NTDCs) by emergency physicians continue to receive attention because of the associated potential for misuse, abuse and addiction. This study examined rates of prescription of opioid analgesics and types of opioid analgesics prescribed for NTDC visits in U.S. emergency departments. Data from the National Hospital Ambulatory Medical Care Survey from 2007 to 2010 were analyzed. Descriptive statistics and logistic regression analysis were performed and adjusted for the survey design. NTDCs made up 1.7% of all ED visits from 2007 to 2010. The prescription of opioid analgesics was 50.3% for NTDC and 14.8% for non-NTDC visits. The overall rate of opioid analgesics prescribed for NTDCs remained fairly stable from 2007 through 2010. Prescription of opioids was highest among patients aged 19-33 years (56.8%), self-paying (57.1%), and non-Hispanic Whites (53.2%). The probability of being prescribed hydrocodone was highest among uninsured patients (68.7%) and for oxycodone, it was highest among private insurance patients (33.6%). Compared to 34-52 year olds, children 0-4 years were significantly more likely to be prescribed codeine and less likely to be prescribed oxycodone. Compared to non-Hispanic Whites, non-Hispanic Blacks had significantly higher odds of been prescribed codeine and somewhat lower odds of been prescribed oxycodone, but it was not statistically significant. There was no significant change in the rates of opioid analgesics prescribed over time for NTDC visits to EDs. Age, payer type and race/ethnicity were significant predictors for the prescription of different opioid analgesics by emergency physicians for NTDC visits. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The impact of pharmacy services on opioid prescribing in dental practice.

PubMed

Stewart, Autumn; Zborovancik, Kelsey J; Stiely, Kara L

To compare rates of dental opioid prescribing between periods of full and partial integration of pharmacy services and periods of no integration. This observational study used a retrospective chart review of opioid prescriptions written by dental providers practicing in a free dental clinic for the medically underserved over a period of 74 months. Pharmacy services were fully integrated into the practice model for 48 of the 74 months under study. During this time frame, all dental opioid orders required review by the pharmacy department before prescribing. Outcomes related to prescribing rates and errors were compared between groups, which were defined by the level of integrated pharmacy services. Demographic and prescription-specific data (drug name, dose, quantity, directions, professional designation of individual entering order) and clinic appointment data were collected and analyzed with the use of descriptive and inferential statistics. A total of 102 opioids were prescribed to 89 patients; hydrocodone-acetaminophen combination products were the most frequently used. Opioid prescribing rates were 5 times greater when pharmacy services were not integrated (P <0.001); and dentists were 81% less likely to prescribe opioids when pharmacy was fully integrated (odds ratio 0.19, 95% confidence interval 0.124-0.293; P <0.001). Frequency of hydrocodone use compared with other opioids did not decrease after the rescheduling of hydrocodone to a Schedule II controlled substance. The frequency of prescribing errors was not statistically different between groups, although there were numerically fewer errors with integrated pharmacy services. The literature reports that dentists are the third most frequent prescribers of opioids. The findings from this study suggest that collaboration between pharmacists and dentists has the potential to decrease opioid utilization in primary dental practice. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Endodontic treatment-related antibiotic prescribing patterns of South African oral health professionals.

PubMed

Lalloo, R; Solanki, G; Ramphoma, K; Myburgh, N G

2017-11-01

To assess the antibiotic prescribing patterns of South African dentists for patients undergoing endodontic treatment. This study used data from 2013 health insurance claims submitted by South African oral health professionals to determine the antibiotic prescribing patterns related to endodontic treatment. A logistic regression model was used to test the fully adjusted statistical significance of the association between the exploratory variables (gender, age group, event type, abscess treatment, chronic health) and the dependent variable (antibiotic prescription). Odds ratios with 95% confidence intervals (CI) are reported, and a 95% CI excluding 1 was considered statistically significant. Almost 10% of endodontic treatments were prescribed an antibiotic. There were no significant differences in prescribing patterns by gender, age and chronic health status. Prescriptions were more common at the preparatory stage (9.4%) of root canal treatment compared to the therapy (4.7%) and canal filling (2%) stages. Patients who received apical surgery (OR = 2.28; 95% CI 1.38-3.76) and treatment of an abscess (OR = 2.57; 95% 1.82-3.63) had a significantly increased odds of being prescribed an antibiotic. Almost three-quarters of prescriptions were for narrow spectrum antibiotics. The frequency of antibiotic prescribing by South African dental practitioners for patients undergoing endodontic treatment is relatively low and predominantly involved narrow spectrum antibiotics. It, however, remains important that antibiotics are only prescribed when clinically essential, such as when there are obvious systemic effects. These include fever above 37 degrees, malaise, lymphadenopathy, trismus, increase swelling, cellulitis, osteomyelitis and persistent infection. The wider dissemination and adherence to clear evidence-based prescribing guidelines for antibiotics in this clinical area are important. © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd.

Parenteral Medication Prescriptions, Dispensing and Administration Habits in Mongolia

PubMed Central

Dorj, Gereltuya; Sunderland, Bruce; Hendrie, Delia; Parsons, Richard

2014-01-01

High levels of injection prescribing were reported in Mongolia. Understanding the factors influencing the injection prescribing is essential to reduce their inappropriate use. The study evaluated the views, experiences and attitudes of community members associated with the prescribing of injections in Mongolia. A structured questionnaire focusing on respondents' characteristics, experiences and views about injections was developed and administered face-to-face to community members in Ulaanbaatar, Mongolia. Standard descriptive statistics were used to summarize demographic data and responses to the questionnaires. Dependant variables were compared using Kruskal-Wallis Tests for independence. Statistical analyses were performed using SPSS Version 21.0. Six hundred participants were approached and the response rate was 79% (n = 474). Almost half of the respondents were aged between 31 and 50 (n = 228, 48.1%) and 40.9% of respondents were male (n = 194). Most respondents were from Ulaanbaatar city (n = 407, 85.7%). All respondents had received injections in the past and 268 (56.5%) had received injection in the past year. The most common reason for having an injection in the past year was reported as treatment of a disease (n = 163, 60.8%), or for administration of vitamins (n = 70, 26.1%). Injections were prescribed by a doctor (n = 353, 74.9%), dispensed by a pharmacist (n = 283, 59.7%) and administered by a nurse (n = 277, 54.9%). Only 16% of all respondents had the expectation of receiving injections when they visited a doctor (n = 77). An important perception regarding injections was that they hastened the recovery process (n = 269, 56.8%). When asked their opinion about therapeutic injections, 40% of all respondents agreed that injections were a better medicine (n = 190) than oral medications, with older respondents strongly agreeing (p<0.001). Based on this total sample, approximately 1891 injections per 1000 patients were administered. The excessive injection use seems to be promoted by inappropriate prescribing, dispensing and administration of medication by doctors and others. PMID:25531766

Using Big Data to Assess Prescribing Patterns in Greece: The Case of Chronic Obstructive Pulmonary Disease.

PubMed

Souliotis, Kyriakos; Kani, Chara; Papageorgiou, Manto; Lionis, Dimitrios; Gourgoulianis, Konstantinos

2016-01-01

Chronic Obstructive Pulmonary Disease (COPD) is one of the top leading causes of death and disability, and its management is focused on reducing risk factors, relieving symptoms, and preventing exacerbations. The study aim was to describe COPD prescribing patterns in Greece by using existing health administrative data for outpatients. This is a retrospective cross-sectional study based on prescriptions collected by the largest social insurance fund, during the first and last trimester of 2012. Selection criteria were the prescription of specific active substances and a COPD diagnosis. Extracted information included active substance, strength, pharmaceutical form and number of packages prescribed, diagnosis, time of dispensing, as well as insurees' age, gender, percentage of co-payment and social security unique number. Statistical analysis included descriptive statistics and logistic regression. 174,357 patients received medicines for COPD during the study period. Patients were almost equally distributed between male and female, and age above 55 years was strongly correlated with COPD. Most patients received a long-acting beta agonist plus inhaled corticosteroid combination (LABA +ICS), followed by long-acting muscarinic agonist (LAMA). 63% patients belonging in the 35-54 age received LABA+ICS. LAMA was prescribed more frequently among males and was strongly correlated with COPD. The study provides big data analysis of Greek COPD prescribing patterns. It highlights the need for appropriate COPD classification in primary care illustrating the role of electronic prescribing in ensuring appropriate prescribing. Moreover, it indicates possible gender differences in treatment response or disease severity, and the impact of statutory co-payments on prescribing.

48 CFR 1852.223-76 - Federal Automotive Statistical Tool Reporting.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Statistical Tool Reporting. 1852.223-76 Section 1852.223-76 Federal Acquisition Regulations System NATIONAL... Provisions and Clauses 1852.223-76 Federal Automotive Statistical Tool Reporting. As prescribed at 1823.271 and 1851.205, insert the following clause: Federal Automotive Statistical Tool Reporting (JUL 2003) If...

14 CFR Sec. 19-2 - Maintenance of data.

Code of Federal Regulations, 2011 CFR

2011-01-01

... operations are reported by the air carrier in operational control of the aircraft. The traffic moving under... shall maintain its operating statistics, covering the movement of traffic in accordance with the uniform classifications prescribed. Codes are prescribed for each operating element and service class. All traffic...

Tree mortality following prescribed fire and a storm surge event in Slash Pine (pinus elliottii var. densa) forests in the Florida Keys, USA

USGS Publications Warehouse

Sah, Jay P.; Ross, Michael S.; Snyder, James R.; Ogurcak, Danielle E.

2010-01-01

In fire-dependent forests, managers are interested in predicting the consequences of prescribed burning on postfire tree mortality. We examined the effects of prescribed fire on tree mortality in Florida Keys pine forests, using a factorial design with understory type, season, and year of burn as factors. We also used logistic regression to model the effects of burn season, fire severity, and tree dimensions on individual tree mortality. Despite limited statistical power due to problems in carrying out the full suite of planned experimental burns, associations with tree and fire variables were observed. Post-fire pine tree mortality was negatively correlated with tree size and positively correlated with char height and percent crown scorch. Unlike post-fire mortality, tree mortality associated with storm surge from Hurricane Wilma was greater in the large size classes. Due to their influence on population structure and fuel dynamics, the size-selective mortality patterns following fire and storm surge have practical importance for using fire as a management tool in Florida Keys pinelands in the future, particularly when the threats to their continued existence from tropical storms and sea level rise are expected to increase.

75 FR 38871 - Proposed Collection; Comment Request for Revenue Procedure 2004-29

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-06

... comments concerning Revenue Procedure 2004-29, Statistical Sampling in Sec. 274 Context. DATES: Written... Internet, at [email protected] . SUPPLEMENTARY INFORMATION: Title: Statistical Sampling in Sec...: Revenue Procedure 2004-29 prescribes the statistical sampling methodology by which taxpayers under...

Prescribing patterns for upper respiratory tract infections: a prescription-review of primary care practice in Kedah, Malaysia, and the implications.

PubMed

Rezal, Rabiatul Salmi; Hassali, Mohamed Azmi; Alrasheedy, Alian A; Saleem, Fahad; Yusof, Faridah Aryani Md; Kamal, Mardhiyah; Mohd Din, Rosminah; Godman, Brian

2015-01-01

It is necessary to ascertain current prescribing of antibiotics for upper respiratory tract infections (URTIs) to address potential overuse. A retrospective analysis was conducted of all prescriptions for URTIs among 10 public primary healthcare centers in Kedah, Malaysia, from 1 January to 31 March 2014. A total of 123,524 prescriptions were screened and analyzed. Of these, 7129 prescriptions were for URTI, with 31.8% (n = 2269) containing antibiotics. Macrolides were the most commonly prescribed antibiotic, constituting 61% (n = 1403) of total antibiotics prescribed. There was a statistically significant association between different prescribers and diagnoses (p = 0.001) and a weak positive trend suggesting family medicine specialists are more competent in antibiotic prescribing, followed by medical officers and assistant medical officers (τ = 0.122). Prescribing practices of some prescribers were inconsistent with current guidelines encouraging resistance development. National antimicrobial stewardship programs and further educational initiatives are ongoing in Malaysia to improve antibiotic use.

Characterization of turbulent coherent structures in square duct flow

NASA Astrophysics Data System (ADS)

Atzori, Marco; Vinuesa, Ricardo; Lozano-Durán, Adrián; Schlatter, Philipp

2018-04-01

This work is aimed at a first characterization of coherent structures in turbulent square duct flows. Coherent structures are defined as connected components in the domain identified as places where a quantity of interest (such as Reynolds stress or vorticity) is larger than a prescribed non-uniform threshold. Firstly, we qualitatively discuss how a percolation analysis can be used to assess the effectiveness of the threshold function, and how it can be affected by statistical uncertainty. Secondly, various physical quantities that are expected to play an important role in the dynamics of the secondary flow of Prandtl’s second kind are studied. Furthermore, a characterization of intense Reynolds-stress events in square duct flow, together with a comparison of their shape for analogous events in channel flow at the same Reynolds number, is presented.

Pharmacist prescribing: a cross-sectional survey of the views of pharmacists in Nigeria.

PubMed

Auta, Asa; Strickland-Hodge, Barry; Maz, Julia; David, Shalkur

2018-04-01

This study was carried out to: (1) explore the views of pharmacists in Nigeria on the extension of prescribing authority to them and determine their willingness to be prescribers and (2) identify the potential facilitators and barriers to introducing pharmacist prescribing in Nigeria. An online cross-sectional survey was conducted from August to October 2014 among 775 pharmacists recruited from the Facebook group of the Pharmaceutical Society of Nigeria using a simple random technique. The questionnaire used for the survey was developed based on the review of the literature and previous qualitative studies conducted in Nigeria. The instrument was evaluated for content validity by two external pharmacy practice researchers and the reliability of items assessed using internal consistency tests. Data obtained from the survey were entered into SPSS v.22, and descriptive statistics were generated. Relationships between variables were evaluated using the chi-square test, and P < 0.05 was considered statistically significant. The response rate was 40.6% (315/775). Three hundred and six (97.1%) respondents agreed that pharmacists should be given prescribing authority. Of these 306, 295 (96.4%) were willing to be prescribers, and just over half of them (148/295; 50.2%) would prefer to prescribe in collaboration with medical doctors. Of those willing to be prescribers, 285 (96.6%) reported that they would need additional training. The most perceived areas of training needed were in the principles of differential diagnosis (81.4%), pathophysiology of diseases (74.0%) and interpretation of laboratory results (68.1%). Respondents identified increasing patients' access to care (308/315; 97.8%) and better utilisation of pharmacists' skills (307/315; 97.5%) as the most likely facilitators to pharmacist prescribing in Nigeria. On the other hand, resistance from the medical doctors (299/315; 94.9%) and pharmacists' inadequate skills in diagnosis (255/315; 81.0%) were perceived as the most likely barriers. Pharmacist prescribing represents an opportunity to promote patients' access to care and the utilisation of pharmacists' skills in Nigeria. The majority of pharmacists showed a positive attitude towards pharmacist prescribing and were willing to be prescribers. The findings of this study could potentially contribute to future medicine prescribing policy and pharmacy practice in Nigeria. © 2017 Royal Pharmaceutical Society.

78 FR 43002 - Proposed Collection; Comment Request for Revenue Procedure 2004-29

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-18

... comments concerning statistical sampling in Sec. 274 Context. DATES: Written comments should be received on... INFORMATION: Title: Statistical Sampling in Sec. 274 Contest. OMB Number: 1545-1847. Revenue Procedure Number: Revenue Procedure 2004-29. Abstract: Revenue Procedure 2004-29 prescribes the statistical sampling...

Effectiveness of Prescribed Fire as a Fuel Treatment in Californian Coniferous Forests

Treesearch

Nicole M. Vaillant; JoAnn Fites-Kaufman; Scott L. Stephens

2006-01-01

Effective fire suppression for the past century has altered forest structure and increased fuel loads. Prescribed fire as a fuels treatment can reduce wildfire size and severity. This study investigates how prescribed fire affects fuel loads, forest structure, potential fire behavior, and modeled tree mortality at 80th, 90th, and 97.5th percentile fire weather...

14 CFR 298.63 - Reporting of aircraft operating expenses and related statistics by small certificated air carriers.

Code of Federal Regulations, 2011 CFR

2011-01-01

... and related statistics by small certificated air carriers. 298.63 Section 298.63 Aeronautics and Space... aircraft operating expenses and related statistics by small certificated air carriers. (a) Each small... Related Statistics.” This schedule shall be filed quarterly as prescribed in § 298.60. Data reported on...

14 CFR 298.63 - Reporting of aircraft operating expenses and related statistics by small certificated air carriers.

Code of Federal Regulations, 2010 CFR

2010-01-01

... and related statistics by small certificated air carriers. 298.63 Section 298.63 Aeronautics and Space... aircraft operating expenses and related statistics by small certificated air carriers. (a) Each small... Related Statistics.” This schedule shall be filed quarterly as prescribed in § 298.60. Data reported on...

[Does the prescribing of antibiotics in paediatrics improve after a multidisciplinary intervention?].

PubMed

Lalana-Josa, Pilar; Laclaustra-Mendizábal, Blanca; Aza-Pascual-Salcedo, M Mercedes; Carcas-de-Benavides, Cristina; Lallana-Álvarez, M Jesús; Pina-Gadea, M Belén

2015-02-01

Antibiotics overuse is linked to elevated antimicrobial resistance. In Aragon, Spain, the highest antibiotic prescription rates occur among children from 1 to 4 years old. The rate of use in this age group is over 60%. To evaluate the effect of multi-faceted intervention on Primary Care paediatricians to reduce antibiotic use and to improve antibiotic prescribing for paediatric outpatients. Outpatient antimicrobial prescribing was analysed before and after an intervention in paediatricians. The intervention included a clinical education session about diagnosis and treatment in the most prevalent paediatric infectious diseases, a clinical interview and communication skills, a workshop on rapid Streptococcus antigen detection test and patient information leaflets and useful internet websites for parents. The control group included paediatricians without this educational intervention on antibiotics. Antibiotic prescribing decreased from 19.17 defined daily doses per 1000 inhabitants/day (DID) to 14.36 DID among intervention paediatricians vs 19.84 DID to 16.02 DID in controls. The decreasing was higher in the intervention group, but the effect was not statistically significant. Macrolides and broad-spectrum penicillins prescribing decreased in both groups. Antibiotic prescribing decreased, but there were no statistically significant differences between the two groups. The high satisfaction of paediatricians in the intervention group makes it necessary to continue with these kinds of strategies to improve antibiotic use in outpatients. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Antibiotic prophylaxis patterns of Finnish dentists performing dental implant surgery.

PubMed

Pyysalo, Mikko; Helminen, Mika; Antalainen, Anna-Kaisa; Sándor, George K; Wolff, Jan

2014-11-01

The peri-operative use of prophylactic antibiotics in clinically healthy patients undergoing dental implant surgery is very common in Finland. While antibiotics are prescribed with the hope of preventing both local and systemic complications, their application and utilization is not uniform. The aim of this study was to assess the variation in prescribing patterns among Finnish dentists performing dental implant placement operations. This study also aimed to examine the possible relationship between early implant removal and the use of the prophylactic antibiotics in Finland. The National Institute for Health and Welfare in Finland granted permission to access the Finnish Dental Implant Register. The peri-operative antibiotic prophylaxis prescribing patterns were assessed in a total of 110 543 dental implant placement procedures and 1038 dental implant removal operations performed in Finland between April 1994 and April 2012. A total of 61 different antibiotics or combinations were prescribed peri-operatively during implant placements in Finland between 1994-2012. Phenoxymethylpenicillin was the most commonly prescribed drug (72.2%). No statistically significant difference in early implant removal rates could be found between patients who had or had not received peri-operative prophylaxis. However, patients who had received peri-operative prophylaxis had statistically significant longer implant survival rates. There is a variation in antibiotic prescribing patterns among Finnish dentists placing dental implants. The results suggest that the use of prophylactic antibiotics has little effect on the prevention of primary implant surgery-related complications and, hence, success rates.

Drug prescribing patterns at primary health care level and related out-of-pocket expenditures in Tajikistan.

PubMed

Donadel, Morgane; Karimova, Gulzira; Nabiev, Ruslan; Wyss, Kaspar

2016-10-06

The Government of Tajikistan is reforming its health system to make access more equitable. Nonetheless, out-of-pocket expenditures (OPE) remain a key modality for purchasing health care. Drugs remain a major driver of household expenditures for health. We conducted a household survey to investigate drug prescribing patterns at primary health care (PHC) level as well as the related OPE. Adult patients in eight districts who had visited a PHC facility in the period March to May 2014 were interviewed at home, using a structured questionnaire. A descriptive analysis was conducted and regression models were constructed to identify factors influencing the number of drugs provided and the types of drugs prescribed. There were 1281 (80.1 %) patients who received a drug prescription after visiting a doctor at PHC level. 16.2 % of them had five or more drugs prescribed concomitantly. The number of drugs prescribed to patients ranged from 0 to 8 and was statistically different across regions (RRS region =3.3; Khatlon region = 3.1; p = 0.05), after adjusting for age and sex. In 31.1 % of cases, prescriptions included an intra-venous (IV) injection; in 45.6 % of cases, a non-IV injection; in 52.9 % of cases, an antibiotic; and in 61.0 % of cases, vitamins. Patients suffering from a respiratory disease had higher odds of being prescribed an IV injection and antibiotics. Vitamins were widely prescribed across all diseases. In 94.5 % of cases, the patients interviewed procured at least one of the prescribed drugs. Among those who received a prescription, 2.0 % were not able to procure at least one drug due to a lack of money. In 94.9 % of cases, respondents reported purchasing drugs in private pharmacies. Median expenditures for drugs procured following consultation were 45 TS (US$ 6.9) corresponding to 77.6 % of total expenditures related to the visit (58 TS, US$ 8.8). In a context where OPE are important, drugs represent an important income source for health service providers. Such a situation does not favour rational prescribing nor efficient service delivery, and is potentially harmful for patients. In particular, the economic ramifications cause high levels of expenditure for patients and households with detrimental, knock-on effects in the more vulnerable segments of the population.

Cardiovascular drugs consumption--comparison between two Croatian regions, City of Zagreb and Lika-Senj County.

PubMed

Jurković, Drazen; Stimac, Danijela; Bajramović, Dubravko; Tiljak, Hrvoje; Stevanović, Ranko

2014-06-01

The aim of this paper is to determine the differences in the outpatient consumption of cardiovascular drugs between Croatian regions: the City of Zagreb and Lika-Senj County. The data on the number of packages and the purchase price for each drug have been obtained from all pharmacies in Lika-Senj County and all pharmacies in the City of Zagreb. Defined daily doses/1000 inhabitants/day (DDD/1000/day) was calculated for every drug in accordance with its code name and Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) index of the World Health Organization (WHO) for 2007. For drug combinations without defined daily doses, equivalent doses (ED) were used. The quality of drug prescribing within the group of cardiovascular drugs was assessed using the Drug Utilization (DU90%) method and the adherence of the DU90% segment to the guidelines for prescribing individual drug groups. The statistical significance of differences in results between the City of Zagreb and Lika-Senj County was tested using the chi-square test at the level of statistical significance p < 0.05. The comparison of the share of the five most often prescribed drug groups in Lika-Senj County has shown statistically significant differences when compared to the City of Zagreb (chi2 = 28.93, df = 4, p < 0.001). The total outpatient consumption of cardiovascular drugs in the City of Zagreb and Lika-Senj County differs significantly. The consumption, quality of prescribing drugs and cost/DDD in the City of Zagreb is higher than in Lika-Senj County; in the City of Zagreb, newer and more expensive drugs are prescribed to a higher extent.

Cardiovascular disease and non-steroidal anti-inflammatory drug prescribing in the midst of evolving guidelines.

PubMed

Pham, Timothy T; Miller, Michael J; Harrison, Donald L; Lloyd, Ann E; Crosby, Kimberly M; Johnson, Jeremy L

2013-12-01

Responding to safety concerns, the American Heart Association (AHA) published guidelines for non-steroidal anti-inflammatory drug (NSAID) use in patients with pre-existing cardiovascular disease (CVD) during 2005 and revised them in 2007. In the revision, a stepped approach to pain management recommended non-selective NSAIDs over highly selective NSAIDs. This research evaluated NSAID prescribing during and after guideline dissemination. A cross-sectional sample of 8666 adult, community-based practice visits with one NSAID prescription representing approximately 305 million visits from the National Ambulatory Medical Care Survey (NAMCS) from 2005 to 2010 was studied. Multivariable logistic regression controlling for patient, provider and visit characteristics assessed the associations between diagnosis of CVD and NSAID type prescribed during each calendar year. Visits were stratified by arthritis diagnosis to model short-term/intermittent and long-term NSAID use. Approximately one-third (36.8%) of visits involving a NSAID prescription included at least one of four diagnoses for CVD (i.e. hypertension, congestive heart failure, ischaemic heart disease or cerebrovascular disease). Visits involving a CVD diagnosis had increased odds of a prescription for celecoxib, a highly selective NSAIDs, overall [adjusted odds ratio (AOR) = 1.29, 95% confidence interval (CI): 1.06-1.57] and in the subgroup of visits without an arthritis diagnosis (AOR = 1.45, 95% CI: 1.11-1.89). Results were not statistically significant for visits with an arthritis diagnosis (AOR = 1.10, 95% CI: 0.47-2.57). When analysed by year, the relationship was statistically significant in 2005 and 2006, but not statistically significant in each subsequent year. National prescribing trends suggest partial implementation of AHA guidelines for NSAID prescribing in CVD from 2005 to 2010. © 2012 John Wiley & Sons Ltd.

A Model for Predicting Thermomechanical Response of Large Space Structures.

DTIC Science & Technology

1985-06-01

Field in a Thermomechanically Heated Viscoplastic ....... Space Truss Structure 6.5 Analysis of a Thermoviscoplastic Uniaxial " Bar Under Prescribed...Stress Part I - Theoretical Development . -- 6.6 Analysis of a Thermoviscoplastic Uniaxial codes Bar Under Prescribed Stress Part II - or Boundary Layer...and Asymptotic Analysis 6.7 Analysis of a Thermoviscoplastic Uniaxial Bar Under Prescribed Stress Part III - Numerical Results for a Bar with Radiative

Long-term effects of prescribed fire on mixed conifer forest structure in the Sierra Nevada, California

USGS Publications Warehouse

van Mantgem, Phillip J.; Stephenson, Nathan L.; Knapp, Eric; Keeley, Jon E.

2011-01-01

The capacity of prescribed fire to restore forest conditions is often judged by changes in forest structure within a few years following burning. However, prescribed fire might have longer-term effects on forest structure, potentially changing treatment assessments. We examined annual changes in forest structure in five 1 ha old-growth plots immediately before prescribed fire and up to eight years after fire at Sequoia National Park, California. Fire-induced declines in stem density (67% average decrease at eight years post-fire) were nonlinear, taking up to eight years to reach a presumed asymptote. Declines in live stem biomass were also nonlinear, but smaller in magnitude (32% average decrease at eight years post-fire) as most large trees survived the fires. The preferential survival of large trees following fire resulted in significant shifts in stem diameter distributions. Mortality rates remained significantly above background rates up to six years after the fires. Prescribed fire did not have a large influence on the representation of dominant species. Fire-caused mortality appeared to be spatially random, and therefore did not generally alter heterogeneous tree spatial patterns. Our results suggest that prescribed fire can bring about substantial changes to forest structure in old-growth mixed conifer forests in the Sierra Nevada, but that long-term observations are needed to fully describe some measures of fire effects.

Does variation among provincial drug formulary antimicrobial listings in Canada influence prescribing rates?

PubMed

Glass-Kaastra, Shiona K; Finley, Rita; Hutchinson, Jim; Patrick, David M; Weiss, Karl; Conly, John

2014-01-01

The financial accessibility of antimicrobial drugs to the outpatient community in Canada is governed at the provincial level through formularies. Each province may choose to list particular drugs or impose restriction criteria on products in order to guide prescribing and/or curtail costs. Although changes to formularies have been shown to change patterns in the use of individual products and alter costs, no comparison has been made among the provincial antimicrobial formularies with regards to flexibility/stringency, or an assessment of how these formularies impact overall antimicrobial use in the provinces. To summarize provincial antimicrobial formularies and assess whether their relative flexibility/stringency had a statistical impact upon provincial prescription volume during a one year period. Provincial drug plan formularies were accessed and summarized for all prescribed antimicrobials in Canada during 2010. The number of general and restricted benefits for each plan was compiled by antimicrobial classification. Population-adjusted prescription rates for all individual antimicrobials and by antimicrobial class were obtained from the Canadian Integrated Program for Antimicrobial Resistance Surveillance. Correlations between the number of general benefits, restricted benefits, and total benefits with the prescription rate in the provinces were assessed by Spearman rank correlation coefficients. Formularies varied considerably among the Canadian provinces. Quebec had the most flexible formulary, offering the greatest number of general benefits and fewest restrictions. In contrast, Saskatchewan's formulary displayed the lowest number of general benefits and most restrictions. Correlation analyses detected a single significant result; macrolide prescription rates decreased as the number of general macrolide benefits increased. All other rates of provincial antimicrobial prescribing and measures of flexibility/stringency revealed no significant correlations. Although antimicrobial formulary listings are used to guide prescribing rates within a province, our analysis of one year's data of the impact of the antimicrobial formulary structure did not correlate with antimicrobial prescribing rates, and other factors are likely to be at play.

The Pattern of Antibiotic Prescribing by Dental Practitioners in Zagreb, Croatia.

PubMed

Perić, Marina; Perković, Ivana; Romić, Martina; Simeon, Paris; Matijević, Jurica; Mehičić, Goranka Prpić; Krmek, Silvana Jukić

2015-06-01

Bacterial resistance is considered a consequence of misuse or overuse of antibiotics. Dentistry significantly contributes to this increasing public health problem. The aim of this cross-sectional study was to examine the pattern of antibiotics prescribed by Croatian dentists in Zagreb area. Out of 220 Doctors of Dental Medicine (DMDs) from Zagreb 110 responded to survey. Prior to the research an ethical approval was obtained. Participants were directly contacted. The questionnaire consisted of two parts: general data on DMDs and the part concerning indications, duration, type and dosage of antibiotic therapy. Data were processed using MS Excel and SPSS for Windows, Version 17.0. Statistical significance was tested by Fisher's exact test, chi-square test, Mann-Whitney U test and Spearman's rank correlation at the level of statistical significance p<0.05. During the period of two months, the doctors prescribed antibiotics to 1,500 patients, 690 (46%) were men and 810 (54%) women. The most often prescribed antibiotics were penicillin (72.5% of patients), represented mostly by amoxicillin in combination with clavulanic acid (57.6%). The most common indication for the prescribed antibiotics was periapical or periodontal abscess (44%). Definite clinical indication (71.2%) was stated as the most common reason for antibiotic prescription. Antibiotic therapy usually lasted 7 days (62.9%). The doctors prescribed daily doses of antibiotics according to the instructions for the use of specific drugs. The examined subjects prescribe antibiotics according to the curriculum taught at the School of Dental Medicine for majority of types, doses and duration of the treatments, although antibiotics over-prescription in cases without medical indication was observed. The national guidelines on antibiotic regimens are required in order to reduce unnecessary antibiotic use. Copyright© by the National Institute of Public Health, Prague 2015.

Childhood Attention-Deficit/Hyperactivity Disorder Prescribing by Prescriber Type and Specialty in Oregon Medicaid.

PubMed

Klein, Tracy A; Panther, Shannon; Woo, Teri; Odom-Maryon, Tamara; Daratha, Kenn

2016-08-01

This study compares nurse practitioner (NP) and physician (MD/DO) prescribing patterns for treatment of children with an attention-deficit/hyperactivity disorder (ADHD)-related diagnosis covered by Oregon Medicaid from 2012 to 2013. This study is a limited data set review of Oregon pharmacy claims for youth aged 3-18 at time of prescription fill, who were continuously enrolled for at least 10 months of the index year. Claims with selected ICD-9 codes (n = 197,364) were further defined by 30-day prescriptions and prescription drug events (PDE) linked to each prescriber type of interest. Descriptive statistical analysis of variables included prescriber type (NP vs. physician) and specialty (generalist vs. specialist), child age, and controlled versus noncontrolled drug type. A total of 82,754 complete 30-day prescriptions for 10,753 children from 1785 unique prescribers (78 NP specialists; 303 NP generalists; 162 physician specialists; and 1242 physician generalist prescribers) and 16,669 PDE were analyzed. Physicians prescribed more than 81% of all ADHD medications, and physician generalists prescribed nearly 60% of all prescriptions. Sixty-four percent of 30-day supply prescriptions (n = 52,678) were controlled substances. Generalists, both NPs and physician prescribers, prescribed controlled medications more often than specialists. Physician specialists consistently prescribed controlled substances for all age groups, while NP specialists prescribed more controlled substances as child age increased. Rates of controlled medications prescribed generally increased, as children got older, regardless of provider type. NPs overall prescribe in a similar pattern to physicians when given the authority to prescribe controlled substances for ADHD. Comparisons between prescriber types for controlled substance prescribing by age should be explored further to identify possible variance from national guidelines.

Tree Mortality following Prescribed Fire and a Storm Surge Event in Slash Pine ( Pinus elliottii var. densa ) Forests in the Florida Keys, USA

DOE PAGES

Sah, Jay P.; Ross, Michael S.; Snyder, James R.; ...

2010-01-01

In fire-dependent forests, managers are interested in predicting the consequences of prescribed burning on postfire tree mortality. We examined the effects of prescribed fire on tree mortality in Florida Keys pine forests, using a factorial design with understory type, season, and year of burn as factors. We also used logistic regression to model the effects of burn season, fire severity, and tree dimensions on individual tree mortality. Despite limited statistical power due to problems in carrying out the full suite of planned experimental burns, associations with tree and fire variables were observed. Post-fire pine tree mortality was negatively correlated withmore » tree size and positively correlated with char height and percent crown scorch. Unlike post-fire mortality, tree mortality associated with storm surge from Hurricane Wilma was greater in the large size classes. Due to their influence on population structure and fuel dynamics, the size-selective mortality patterns following fire and storm surge have practical importance for using fire as a management tool in Florida Keys pinelands in the future, particularly when the threats to their continued existence from tropical storms and sea level rise are expected to increase.« less

Use of Exogenous Testosterone for the Treatment of Male Factor Infertility: A Survey of Nigerian Doctors.

PubMed

Omisanjo, Olufunmilade Akinfolarin; Ikuerowo, Stephen Odunayo; Abdulsalam, Moruf Adekunle; Ajenifuja, Sheriff Olabode; Shittu, Khadijah Adebisi

2017-01-01

Though exogenous testosterone is known for its contraceptive effects in men, it is sometimes prescribed by medical practitioners for the treatment of male factor infertility in the mistaken belief that exogenous testosterone improves sperm count. The aim of this study was to evaluate the scope of testosterone use in the treatment of male factor infertility by medical practitioners in Lagos, Nigeria. A survey using a structured questionnaire was carried out amongst doctors attending a regular Continuing Medical Education (CME) programme in Lagos, Nigeria. There were 225 respondents. Most of the respondents (69.8%, n = 157) indicated that exogenous testosterone increases sperm count. Only 22 respondents (9.8%) indicated (correctly) that exogenous testosterone decreases sperm count. Seventy-seven respondents (34.2%) had prescribed some form of exogenous testosterone in the treatment of male factor infertility. The vast majority of respondents who had prescribed testosterone (81.8%, n = 63) thought exogenous testosterone increases sperm count. There was no statistically significant difference in the pattern of prescription across the respondents' specialty ( p = 0.859) or practice type ( p = 0.747). The misuse of exogenous testosterone for the treatment of male infertility was common amongst the respondents, with most of them wrongly believing that exogenous testosterone increases sperm count.

Implementation of additional prescribing authorization among oncology pharmacists in Alberta.

PubMed

Au, Bianca; Dersch-Mills, Deonne; Ghosh, Sunita; Jupp, Jennifer; Chambers, Carole; Cusano, Frances; Danilak, Melanie

2018-01-01

Purpose To describe the practice settings and prescribing practices of oncology pharmacists with additional prescribing authorization. Methods A descriptive, cross-sectional survey of all oncology pharmacists in Alberta was conducted using a web-based questionnaire over four weeks between March and April 2016. Pharmacists were identified from the Cancer Services Pharmacy Directory and leadership staff in Alberta Health Services. Descriptive statistics were used to describe the practice setting, prescribing practices, motivators to apply for additional prescribing authorization, and the facilitators and barriers of prescribing. Logistic regression was used to explore factors associated with having additional prescribing authorization. Results The overall response rate was 41% (71 of 175 pharmacists). Oncology pharmacists with additional prescribing authorization made up 38% of respondents. They primarily worked in urban, tertiary cancer centers, and practiced in ambulatory care. The top 3 clinical activities they participated in were medication reconciliation, medication counseling/education, and ambulatory patient assessment. Respondents thought additional prescribing authorization was most useful for ambulatory patient assessment and follow-up. Antiemetics were prescribed the most often. The median number of prescriptions written in an average week of clinical work was 5. Competence, self-confidence, and the potential impact on patient care/perceived impact on work environment were the strongest facilitators of prescribing. The strongest motivators to apply for additional prescribing authorization were relevancy to practice, the potential for increased efficiency, and advancing the profession. Conclusion The current majority of oncology pharmacist prescribing in Alberta occurs in ambulatory care with a large focus on antiemetic prescribing. Pharmacists found additional prescribing authorization most useful for ambulatory patient assessment and follow-up.

Probabilistic finite elements for fatigue and fracture analysis

NASA Astrophysics Data System (ADS)

Belytschko, Ted; Liu, Wing Kam

Attenuation is focused on the development of Probabilistic Finite Element Method (PFEM), which combines the finite element method with statistics and reliability methods, and its application to linear, nonlinear structural mechanics problems and fracture mechanics problems. The computational tool based on the Stochastic Boundary Element Method is also given for the reliability analysis of a curvilinear fatigue crack growth. The existing PFEM's have been applied to solve for two types of problems: (1) determination of the response uncertainty in terms of the means, variance and correlation coefficients; and (2) determination the probability of failure associated with prescribed limit states.

Probabilistic finite elements for fatigue and fracture analysis

NASA Technical Reports Server (NTRS)

Belytschko, Ted; Liu, Wing Kam

1992-01-01

Attenuation is focused on the development of Probabilistic Finite Element Method (PFEM), which combines the finite element method with statistics and reliability methods, and its application to linear, nonlinear structural mechanics problems and fracture mechanics problems. The computational tool based on the Stochastic Boundary Element Method is also given for the reliability analysis of a curvilinear fatigue crack growth. The existing PFEM's have been applied to solve for two types of problems: (1) determination of the response uncertainty in terms of the means, variance and correlation coefficients; and (2) determination the probability of failure associated with prescribed limit states.

HL7 Structured Product Labeling - electronic prescribing information for provider order entry decision support.

PubMed

Schadow, Gunther

2005-01-01

Prescribing errors are an important cause of adverse events, and lack of knowledge of the drug is a root cause for prescribing errors. The FDA is issuing new regulations that will make the drug labels much more useful not only to physicians, but also to computerized order entry systems that support physicians to practice safe prescribing. For this purpose, FDA works with HL7 to create the Structured Product Label (SPL) standard that includes a document format as well as a drug knowledge representation, this poster introduces the basic concepts of SPL.

Pattern of Self Prescribed Analgesic Use in a Rural Area of Delhi: Exploring the Potential Role of Internet.

PubMed

Kochhar, Anjali; Gupta, Tanya

2017-07-01

Analgesics are the most common self prescribed drugs. Although considered to be relatively safe, side effects are often seen when these drugs are used for prolonged period, in high doses or used where contraindicated. Majority of the consumers are not aware of the side effects. These days ample amount of information is available on web, it is important to explore its role in educating the population regarding the safe use of self prescribed analgesics. To explore pattern of analgesic use, to identify population at risk of developing side effects related to analgesic use, awareness of side effects and potential role of internet to bring awareness about safe use of self prescribed analgesic drugs in a rural area of Delhi. A cross-sectional survey based study was done on 500 adults in the age group of 18-65 years of Madanpur Khadar area of South Delhi, India. Data collection was done by conducting visits to pharmacy shops from the people who were buying drugs without prescription and taking face to face interviews using a semi-structured questionnaire. Statistical analysis was performed using descriptive tests with Microsoft office excel 2007. Results of our study showed that among all the self prescribed analgesics paracetamol (57%) was used most frequently followed by aspirin and other NSAIDs. It was found that 9.6% of the consumers were having associated co-morbid illness, 11.4% were simultaneously taking other drugs and 15.2% were alcoholics. Majority (65.4%) of the buyers were not aware about any kind of side effects of the analgesics. Internet friendly consumers were found to be 44%. Ability to use internet and education level were found to be directly related (r=0.802). The pattern of analgesic consumption in the rural population of Delhi shows that a large number of consumers may be at risk of developing side effects of self prescribed analgesics. The awareness about the side effects is limited. A significant number of consumers are internet friendly. Hence, we recommend use of website/mobile apps as potential source of information in educating the population regarding the use of self prescribed analgesics.

Evaluation of a complex intervention to improve primary care prescribing: a phase IV segmented regression interrupted time series analysis

PubMed Central

MacBride-Stewart, Sean; Marwick, Charis; Houston, Neil; Watt, Iain; Patton, Andrea; Guthrie, Bruce

2017-01-01

Background It is uncertain whether improvements in primary care high-risk prescribing seen in research trials can be realised in the real-world setting. Aim To evaluate the impact of a 1-year system-wide phase IV prescribing safety improvement initiative, which included education, feedback, support to identify patients to review, and small financial incentives. Design and setting An interrupted time series analysis of targeted high-risk prescribing in all 56 general practices in NHS Forth Valley, Scotland, was performed. In 2013–2014, this focused on high-risk non-steroidal anti-inflammatory drugs (NSAIDs) in older people and NSAIDs with oral anticoagulants; in 2014–2015, it focused on antipsychotics in older people. Method The primary analysis used segmented regression analysis to estimate impact at the end of the intervention, and 12 months later. The secondary analysis used difference-in-difference methods to compare Forth Valley changes with those in NHS Greater Glasgow and Clyde (GGC). Results In the primary analysis, downward trends for all three NSAID measures that were existent before the intervention statistically significantly steepened following implementation of the intervention. At the end of the intervention period, 1221 fewer patients than expected were prescribed a high-risk NSAID. In contrast, antipsychotic prescribing in older people increased slowly over time, with no intervention-associated change. In the secondary analysis, reductions at the end of the intervention period in all three NSAID measures were statistically significantly greater in NHS Forth Valley than in NHS GGC, but only significantly greater for two of these measures 12 months after the intervention finished. Conclusion There were substantial and sustained reductions in the high-risk prescribing of NSAIDs, although with some waning of effect 12 months after the intervention ceased. The same intervention had no effect on antipsychotic prescribing in older people. PMID:28347986

Evaluation of a complex intervention to improve primary care prescribing: a phase IV segmented regression interrupted time series analysis.

PubMed

MacBride-Stewart, Sean; Marwick, Charis; Houston, Neil; Watt, Iain; Patton, Andrea; Guthrie, Bruce

2017-05-01

It is uncertain whether improvements in primary care high-risk prescribing seen in research trials can be realised in the real-world setting. To evaluate the impact of a 1-year system-wide phase IV prescribing safety improvement initiative, which included education, feedback, support to identify patients to review, and small financial incentives. An interrupted time series analysis of targeted high-risk prescribing in all 56 general practices in NHS Forth Valley, Scotland, was performed. In 2013-2014, this focused on high-risk non-steroidal anti-inflammatory drugs (NSAIDs) in older people and NSAIDs with oral anticoagulants; in 2014-2015, it focused on antipsychotics in older people. The primary analysis used segmented regression analysis to estimate impact at the end of the intervention, and 12 months later. The secondary analysis used difference-in-difference methods to compare Forth Valley changes with those in NHS Greater Glasgow and Clyde (GGC). In the primary analysis, downward trends for all three NSAID measures that were existent before the intervention statistically significantly steepened following implementation of the intervention. At the end of the intervention period, 1221 fewer patients than expected were prescribed a high-risk NSAID. In contrast, antipsychotic prescribing in older people increased slowly over time, with no intervention-associated change. In the secondary analysis, reductions at the end of the intervention period in all three NSAID measures were statistically significantly greater in NHS Forth Valley than in NHS GGC, but only significantly greater for two of these measures 12 months after the intervention finished. There were substantial and sustained reductions in the high-risk prescribing of NSAIDs, although with some waning of effect 12 months after the intervention ceased. The same intervention had no effect on antipsychotic prescribing in older people. © British Journal of General Practice 2017.

Current trends in treatment of hypertension in Karachi and cost minimization possibilities.

PubMed

Hussain, Izhar M; Naqvi, Baqir S; Qasim, Rao M; Ali, Nasir

2015-01-01

This study finds out drug usage trends in Stage I Hypertensive Patients without any compelling indications in Karachi, deviations of current practices from evidence based antihypertensive therapeutic guidelines and looks for cost minimization opportunities. In the present study conducted during June 2012 to August 2012, two sets were used. Randomized stratified independent surveys were conducted in doctors and general population - including patients, using pretested questionnaires. Sample sizes for doctors and general population were 100 and 400 respectively. Statistical analysis was conducted on Statistical Package for Social Science (SPSS). Financial impact was also analyzed. On the basis of patients' doctors' feedback, Beta Blockers, and Angiotensin Converting Enzyme Inhibitors were used more frequently than other drugs. Thiazides and low-priced generics were hardly prescribed. Beta blockers were prescribed widely and considered cost effective. This trend increases cost by two to ten times. Feedbacks showed that therapeutic guidelines were not followed by the doctors practicing in the community and hospitals in Karachi. Thiazide diuretics were hardly used. Beta blockers were widely prescribed. High priced market leaders or expensive branded generics were commonly prescribed. Therefore, there are great opportunities for cost minimization by using evidence-based clinically effective and safe medicines.

Antibiotic prescribing during office hours and out-of-hours: a comparison of quality and quantity in primary care in the Netherlands

PubMed Central

Debets, Vera EC; Verheij, Theo JM; van der Velden, Alike W

2017-01-01

Background Unnecessary and non-first-choice antibiotic prescribing is a significant problem in primary care. It is often argued that irrational prescribing is higher during out-of-hours (OOH) consultations. Aim To obtain insight into the quantity and quality of OOH antibiotic prescribing for commonly presented infectious diseases. Design and setting Two two-way comparisons of 1) nationally dispensed antibiotics during office hours and OOH care, using data from the Dutch Foundation of Pharmaceutical Statistics, and 2) regional prescribing quality data from 45 primary care practices from Utrecht and its vicinity, and two large OOH services in Utrecht and Woerden. Method From the national data, yearly dispensed antibiotics were analysed per prescriber type, with respect to time (office hours or OOH) of prescription, types of antibiotics, and patients’ age group. Regional prescribing rates, choice of antibiotic, and appropriateness of prescribing were compared for otitis media, sinusitis, tonsillitis, bronchitis, cystitis, and impetigo. Appropriateness was assessed by comparing all relevant information from medical files with the guideline recommendations. Results Only 6% of GP-prescribed antibiotics were prescribed OOH. OOH, cystitis and acute otitis media presented most often. First-choice prescribing was comparable for the two settings, whereas prescribing rates were higher OOH, with comparatively more amoxicillin(/clavulanate). The appropriateness evaluation, however, revealed that overprescribing was comparable, or even lower than, for daily practice. Conclusion The suggestion that OOH antibiotic prescribing quality is worse than in daily practice does not seem founded. The higher OOH prescribing rates can be explained by a different population of presenting patients. The appropriateness of prescribing rather than prescribing rates, therefore, should be used to determine quality. PMID:28232364

Prescribed fire as the minimum tool for wilderness forest and fire regime restoration: a case study from the Sierra Nevada, California

Treesearch

MaryBeth Keifer; Nathan L. Stephenson; Jeff Manley

2000-01-01

Changes in forest structure were monitored in areas treated with prescribed fire in Sequoia and Kings Canyon National Parks. Five years after the initial prescribed fires, tree density was reduced by 61% in the giant sequoia-mixed conifer forest, with the greatest reduction in the smaller trees. This post-burn forest structure falls within the range that may have been...

[Pharmacoeconomic indicators of cardiovascular drug utilization in the Republic of Croatia and city of Zagreb in 2008].

PubMed

Stimac, Danijela; Stambuk, Ivanka

2010-12-01

In comparison with original drugs, generic drugs have the same efficacy but considerably lower price and should therefore be preferred to original drugs on prescribing. The aim of the present study was to assess outpatient utilization and rationality of cardiovascular drug prescribing in the City of Zagreb and Republic of Croatia based on the generic to original drug prescribing ratio. Data on the financial indicators and number of cardiovascular drug packages issued in 2008 were obtained from the Croatian Institute of Health Insurance. These data were used to calculate the number of defined daily doses (DDD) and number of DDD per 1000 inhabitants per day (DDD/1000/day). The index of generic/original drug utilization was determined for Zagreb and Croatia as a measure for assessment of prescribing rationality; the significance of difference was determined by X2-test. The rate of prescribing original cardiovascular drugs was significantly higher in Zagreb as compared with Croatia as a whole. The index of prescribing generic versus original drugs was 1.20 (249/208 DDD/1000/day) in Zagreb and 1.65 (249/151 DDD/1000/day) in Croatia. Difference in the utilization of generic drugs between Zagreb and Croatia as determined by X2-test (the level of statistical significance was set at P<0.05) was statistically significant (P=0.021). The highest differences were recorded in the most widely prescribed drug groups, i.e. ACE inhibitors with the generic/original drug index of 1.38 in Zagreb and 2.02 in Croatia; and hypolipemics with the generic/original drug index of 0.96 in Zagreb and 1.34 in Croatia. According to financial indicators, the generic/original drug index was 1.44 in Croatia and only 0.96 in Zagreb. The significantly greater influence of pharmaceutical industry marketing in Zagreb entailed the significantly higher rate of original drug prescribing, which is associated with considerably greater drug expenses. Measures to stimulate prescribing generic drugs should be launched at the national level.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs.

PubMed

Penfold, Robert B; Burgess, James F; Lee, Austin F; Li, Mingfei; Miller, Christopher J; Nealon Seibert, Marjorie; Semla, Todd P; Mohr, David C; Kazis, Lewis E; Bauer, Mark S

2018-02-01

To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA. VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database. We conducted a retrospective space-time cluster analysis using the space-time permutation statistic. All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication. The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely. Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics. © Health Research and Educational Trust.

Dental students' compliance with antibiotic prescribing guidelines for dental infections in children.

PubMed

Wong, Yee Chen; Mohan, Mandakini; Pau, Allan

2016-01-01

To investigate the antibiotic prescribing training received by dental students, clinical experience in treating child patients, awareness of antibiotic prescribing guidelines, preparedness in antibiotic prescribing, and compliance with antibiotic prescribing guidelines for the management of dental infections in children. This was a cross-sectional study involving final year dentals students from Malaysian and Asian dental schools. A self-administered questionnaire consisting of five clinical case scenarios was e-mailed to all final year students at selected dental schools. Students' responses were compared for each clinical case scenario with the prescribing guidelines of the American Academy of Pediatric Dentistry and the American Dental Association. Compliance in each scenario was tested for association with their preparedness in antibiotic prescribing, previous training on antibiotic prescribing and awareness of antibiotic prescribing guidelines using Chi-square test. Data collected were analyzed using SPSS statistics version 20. A total of 108 completed responses were received. About 74 (69%) students were from Malaysian dental schools. The compliance rate with prescribing guidelines ranged from 15.7% to 43.5%. Those attending Malaysian dental schools (47.3%) and those who had treated child patient more often (46.3%) were more likely (P < 0.05) to be aware of the guidelines. Those who had received antibiotic prescribing training (21.3%) were more likely to think they were well prepared in antibiotic prescribing (P < 0.05). Final year dental students had low awareness and compliance with antibiotic prescribing guidelines. Further research is needed to investigate how compliance with the guidelines may be enhanced.

The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain.

PubMed

Stenner, Karen; Courtenay, Molly

2008-08-01

This paper is a report of a study to explore nurse prescribers' views on the role of inter-professional relationships and other means of support for nurse prescribing for patients in acute and chronic pain. Research indicates that good team relationships are important for supporting nurse prescribing but that poor understanding of the role by other healthcare professionals can act as a barrier. While collaborative working is central to the role of pain nurses, there is a lack of research on the impact of nurse prescribing on inter-professional working or the support needs of these nurses. A qualitative approach was adopted using thematic analysis of semi-structured interview data collected during 2006 and 2007. Participants were 26 nurses who prescribed medicines for patients with acute and/or chronic pain. Nurses' believed that prescribing encouraged collaborative working and sharing of knowledge across professional boundaries and that this helped to broaden understanding of the wider remit of pain management. Collaboration with doctors served a number of functions, including support and continuous learning. Barriers to effective nurse prescribing were a lack of understanding of its role amongst healthcare professionals and inadequate support. Formal support structures, such as regular clinical supervision, were seen as crucial to meeting nurses' ongoing learning. Factors that promote understanding of nurse prescribing and support inter-professional relationships are likely to have a positive impact on the effectiveness of nurse prescribing. A more consistent approach is required within organisations to support nurse prescribing.

Response of Legumes to Prescribed Burns in Loblolly Pine Stands of the South Carolina Piedmont

Treesearch

Charles T. Cushwa; Melvin Hopkins; Burd S. McGinnes

1970-01-01

The effects of prescribed burns in spring or summer on the leguminous plant cover and on seed production of legumes were studied at nine locations on the Sumter National Forest in the Piedmont of South Carolina. Numbers of legumes did not differ statistically from those on unburned control plots. Seed production on plots burned during the summer was significantly...

Prescribing behaviour after the introduction of decentralized drug budgets: Is there an association with employer and type of care facility?

PubMed Central

Andersson, Karolina; Carlsten, Anders; Hedenrud, Tove

2009-01-01

Objective To analyse whether prescribing patterns changed after introduction of drug budgets and whether there is an association between drug prescribing patterns and the type of employer and care facility. Methods Data analysed encompassed information on dispensed medicines, by workplaces, prescribed in the Region Västra Götaland, Sweden, for the years 2003 and 2006. Workplaces (n = 969) were categorized according to type of employer and type of care facility. Five prescribing indicators reflecting goals for cost-containing prescribing in Region Västra Götaland were assessed. Changes over time and differences between different types of employer and care facility were analysed by Mann–Whitney tests. Results In 2003, workplaces with a public employer had a significantly higher adherence to three of the prescribing indicators compared with private practitioners. Two of these differences remained in 2006. In 2003, none of the prescribing indicators differed between primary care and other care facilities. Three years later workplaces in primary care had a significantly higher adherence to three of the prescribing indicators than other care facilities. There was a statistically significant difference in change between 2003 and 2006 between primary care and other care facilities; there were no differences in change between workplaces with public and private employers. Conclusions Adherence to three of the prescribing indicators increased after the introduction of decentralized drug budgets. Workplaces with a public employer showed greater adherence to two of the prescribing indicators than private sector workplaces. PMID:19291589

'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing.

PubMed

Lloyd, Fran; Parsons, Carole; Hughes, Carmel M

2010-02-01

Supplementary prescribing has seen pharmacists assume greater responsibility for prescribing in collaboration with doctors. This study explored the context and experiences, in relation to the practice of supplementary prescribing, of pharmacists and physicians (who acted as their training mentors) at least 12 months after pharmacists had qualified as supplementary prescribers. The setting was primary and secondary healthcare sectors in Northern Ireland. Pharmacists and mentors who had participated in a pre-training study were invited to take part. All pharmacists (n = 47) were invited to participate in focus groups, while mentors (n = 35) were asked to participate in face-to-face semi-structured interviews. The research took place between May 2005 and September 2007. All discussions and interviews were audiotaped, transcribed and analysed using constant comparison. Nine pharmacist focus groups were convened (number per group ranging from three to six; total n = 40) and 31 semi-structured interviews with mentors were conducted. The six main themes that emerged were optimal practice setting, professional progression for prescribing pharmacists, outcomes for prescribing pharmacists, mentors and patients, relationships, barriers to implementation and the future of pharmacist prescribing. Where practised, pharmacist prescribing had been accepted, worked best for chronic disease management, was perceived to have reduced doctors' workload and improved continuity of care for patients. However, three-quarters of pharmacists qualified to practise as supplementary prescribers were not actively prescribing, largely due to logistical and organisational barriers rather than inter-professional tensions. Independent prescribing was seen as contentious by mentors, particularly because of the diagnostic element. Supplementary prescribing has been successful where it has been implemented but a number of barriers remain which are preventing the wider acceptance of this practice innovation.

Effects of creating two forest structures and using prescribed fire on coarse woody debris in northeastern California, USA

Treesearch

Fabian C. C. Uzoh; Carl N. Skinner

2009-01-01

Little is known about the dynamics of coarse woody debris (CWD) in forests that were originally characterized by frequent, low-moderate intensity fires. We investigated effects of prescribed burning at the Blacks Mountain Experimental Forest in northeastern California following creation of two stand structure conditions: 1) high structural diversity (HiD) that included...

An improved approach for flight readiness certification: Probabilistic models for flaw propagation and turbine blade failure. Volume 1: Methodology and applications

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for designs failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.

An improved approach for flight readiness certification: Probabilistic models for flaw propagation and turbine blade failure. Volume 2: Software documentation

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflights systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for design, failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Medeiros, Brian; Williamson, David L.; Olson, Jerry G.

In this study, fundamental characteristics of the aquaplanet climate simulated by the Community Atmosphere Model, Version 5.3 (CAM5.3) are presented. The assumptions and simplifications of the configuration are described. A 16 year long, perpetual equinox integration with prescribed SST using the model’s standard 18 grid spacing is presented as a reference simulation. Statistical analysis is presented that shows similar aquaplanet configurations can be run for about 2 years to obtain robust climatological structures, including global and zonal means, eddy statistics, and precipitation distributions. Such a simulation can be compared to the reference simulation to discern differences in the climate, includingmore » an assessment of confidence in the differences. To aid such comparisons, the reference simulation has been made available via earthsystemgrid.org. Examples are shown comparing the reference simulation with simulations from the CAM5 series that make different microphysical assumptions and use a different dynamical core.« less

Reference aquaplanet climate in the Community Atmosphere Model, Version 5

DOE PAGES

Medeiros, Brian; Williamson, David L.; Olson, Jerry G.

2016-03-18

In this study, fundamental characteristics of the aquaplanet climate simulated by the Community Atmosphere Model, Version 5.3 (CAM5.3) are presented. The assumptions and simplifications of the configuration are described. A 16 year long, perpetual equinox integration with prescribed SST using the model’s standard 18 grid spacing is presented as a reference simulation. Statistical analysis is presented that shows similar aquaplanet configurations can be run for about 2 years to obtain robust climatological structures, including global and zonal means, eddy statistics, and precipitation distributions. Such a simulation can be compared to the reference simulation to discern differences in the climate, includingmore » an assessment of confidence in the differences. To aid such comparisons, the reference simulation has been made available via earthsystemgrid.org. Examples are shown comparing the reference simulation with simulations from the CAM5 series that make different microphysical assumptions and use a different dynamical core.« less

Precipitation in a boiling soup: is microphysics driving the statistical properties of intense turbulent convection?

NASA Astrophysics Data System (ADS)

Parodi, A.; von Hardenberg, J.; Provenzale, A.

2012-04-01

Intense precipitation events are often associated with strong convective phenomena in the atmosphere. A deeper understanding of how microphysics affects the spatial and temporal variability of convective processes is relevant for many hydro-meteorological applications, such as the estimation of rainfall using remote sensing techniques and the ability to predict severe precipitation processes. In this paper, high-resolution simulations (0.1-1 km) of an atmosphere in radiative-convective equilibrium are performed using the Weather Research and Forecasting (WRF) model by prescribing different microphysical parameterizations. The dependence of fine-scale spatio-temporal properties of convective structures on microphysical details are investigated and the simulation results are compared with the known properties of radar maps of precipitation fields. We analyze and discuss similarities and differences and, based also on previous results on the dependence of precipitation statistics on the raindrop terminal velocity, try to draw some general inferences.

Prescribed burning consumes key forest structural components: implications for landscape heterogeneity.

PubMed

Holland, Greg J; Clarke, Michael F; Bennett, Andrew F

2017-04-01

Prescribed burning to achieve management objectives is a common practice in fire-prone regions worldwide. Structural components of habitat that are combustible and slow to develop are particularly susceptible to change associated with prescribed burning. We used an experimental, "whole-landscape" approach to investigate the effect of differing patterns of prescribed burning on key habitat components (logs, stumps, dead trees, litter cover, litter depth, and understorey vegetation). Twenty-two landscapes (each ~100 ha) were selected in a dry forest ecosystem in southeast Australia. Experimental burns were conducted in 16 landscapes (stratified by burn extent) while six served as untreated controls. We measured habitat components prior to and after burning. Landscape burn extent ranged from 22% to 89% across the 16 burn treatments. With the exception of dead standing trees (no change), all measures of habitat components declined as a consequence of burning. The degree of loss increased as the extent to which a landscape was burned also increased. Prescribed burning had complex effects on the spatial heterogeneity (beta diversity) of structural components within landscapes. Landscapes that were more heterogeneous pre-fire were homogenized by burning, while those that were more homogenous pre-fire tended to display greater differentiation post-burning. Thus, the notion that patch mosaic burning enhances heterogeneity at the landscape-scale depends on prior conditions. These findings have important management implications. Where prescribed burns must be undertaken, effects on important resources can be moderated via control of burn characteristics (e.g., burn extent). Longer-term impacts of prescribed burning will be strongly influenced by the return interval, given the slow rate at which some structural components accumulate (decades to centuries). Management of habitat structural components is important given the critical role they play in (1) provision of habitat resources for diverse organisms, (2) retention of moisture and nutrients in otherwise dry, low-productivity systems, and (3) carbon storage. © 2016 by the Ecological Society of America.

Prescribed fire in upland harwood forests

Treesearch

T.L. Keyser; C.H. Greenberg; H. McNab

2014-01-01

In upland hardwood forests of the Southeastern U.S.,prescribed fire is increasingly used by land managers citing objectives that include hazardous fuels reduction, wildlife habitat improvement, promoting oak regeneration, or restoring forest composition or structure to an historic condition. Research suggests that prescribed fire effects on hardwood forests and...

Prescribing for pain--how do nurses contribute? A national questionnaire survey.

PubMed

Stenner, Karen; Carey, Nicola; Courtenay, Molly

2012-12-01

To provide information on the profile and practice of nurses in the UK who prescribe medication for pain. Pain is widely under-reported and under-treated and can have negative consequences for health and psychosocial well-being. Indications are that nurses can improve treatment and access to pain medications when they prescribe. Whilst nurses working in many practice areas treat patients with pain, little is known about the profile, prescribing practice or training needs of these nurses. A descriptive questionnaire survey. An online questionnaire was used to survey 214 nurses who prescribed for pain in the UK between May and July 2010. Data were analysed using descriptive statistics and non-parametric tests. Half the participants (50%) worked in primary care, 32% in secondary care and 14% worked across care settings. A range of services were provided, including general practice, palliative care, pain management, emergency care, walk-in-centres and out-of-hours. The majority (86%) independently prescribed 1-20 items per week. Non-opioid and weak opioids analgesics were prescribed by most (95%) nurses, whereas fewer (35%) prescribed strong opioids. Training in pain had been undertaken by 97% and 82% felt adequately trained, although 28% had problems accessing training. Those with specialist training prescribed a wider range of pain medications, were more likely to prescribe strong opioids and were more often in pain management roles. Nurses prescribe for pain in a range of settings with an emphasis on the treatment of minor ailments and acute pain. A range of medications are prescribed, and most nurses have access to training. The nursing contribution to pain treatment must be acknowledged within initiatives to improve pain management. Access to ongoing training is required to support nurse development in this area of practice to maximise benefits. © 2012 Blackwell Publishing Ltd.

A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: a novel implementation strategy for adopting clinical guidelines for Opioid prescribing in primary care.

PubMed

Quanbeck, Andrew; Brown, Randall T; Zgierska, Aleksandra E; Jacobson, Nora; Robinson, James M; Johnson, Roberta A; Deyo, Brienna M; Madden, Lynn; Tuan, Wen-Jan; Alagoz, Esra

2018-01-25

This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named "systems consultation" aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels. We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques. Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: "I am more familiar with guidelines for safe opioid prescribing" and "My clinic's workflow for opioid prescribing is easier." At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes. The systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare. ClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496 Registered May 5, 2015.

Soil responses to the fire and fire surrogate study in the Sierra Nevada

Treesearch

Emily E.Y. Moghaddas; Scott L. Stephens

2007-01-01

The Fire and Fire Surrogate Study utilizes forest thinning and prescribed burning in attempt to create forest stand structures that reduce the risk of catastrophic wildfire. Replicated treatments consisting of mechanical tree harvest (commercial harvest plus mastication of submerchantable material), mechanical harvest followed by prescribed fire, prescribed fire alone...

Statin initiation by GPs in WA--a structured vignette study.

PubMed

Stafford, Leanne; Harmer, Nichola; Dhaliwal, Satvinder; Jiwa, Moyez

2009-09-01

Statins are recommended for all patients with known coronary heart disease. This pilot study investigated statin initiation by a Western Australian general practitioner cohort and the influence of prescriber and patient characteristics on prescribing. A structured vignette questionnaire was posted to members of the Fremantle GP Network. Respondents indicated their prescribing decisions for nine hypothetical patients who had recently suffered a myocardial infarction. Data analysis utilised logistic regression analyses and a generalised linear model with a logit link function. Fifty-five GPs responded (16.0% response rate). In over 20% of cases a statin was not prescribed. Male (OR 4.71; 95% CI: 1.24-17.87) and GPs with fewer years in practice (4.50; 1.21-16.77) were more likely to prescribe appropriately. Younger patients (2.21; 1.38-3.53), and those with diabetes (1.74; 1.09-2.76) or hypercholesterolaemia (4.81; 2.88-8.03) were more likely to receive therapy. Prescribing practices failed to comply with current guidelines in a significant number of cases. Further research to confirm these findings is warranted.

Time-to-event methodology improved statistical evaluation in register-based health services research.

PubMed

Bluhmki, Tobias; Bramlage, Peter; Volk, Michael; Kaltheuner, Matthias; Danne, Thomas; Rathmann, Wolfgang; Beyersmann, Jan

2017-02-01

Complex longitudinal sampling and the observational structure of patient registers in health services research are associated with methodological challenges regarding data management and statistical evaluation. We exemplify common pitfalls and want to stimulate discussions on the design, development, and deployment of future longitudinal patient registers and register-based studies. For illustrative purposes, we use data from the prospective, observational, German DIabetes Versorgungs-Evaluation register. One aim was to explore predictors for the initiation of a basal insulin supported therapy in patients with type 2 diabetes initially prescribed to glucose-lowering drugs alone. Major challenges are missing mortality information, time-dependent outcomes, delayed study entries, different follow-up times, and competing events. We show that time-to-event methodology is a valuable tool for improved statistical evaluation of register data and should be preferred to simple case-control approaches. Patient registers provide rich data sources for health services research. Analyses are accompanied with the trade-off between data availability, clinical plausibility, and statistical feasibility. Cox' proportional hazards model allows for the evaluation of the outcome-specific hazards, but prediction of outcome probabilities is compromised by missing mortality information. Copyright © 2016 Elsevier Inc. All rights reserved.

Monte Carlo simulation methodology for the reliabilty of aircraft structures under damage tolerance considerations

NASA Astrophysics Data System (ADS)

Rambalakos, Andreas

Current federal aviation regulations in the United States and around the world mandate the need for aircraft structures to meet damage tolerance requirements through out the service life. These requirements imply that the damaged aircraft structure must maintain adequate residual strength in order to sustain its integrity that is accomplished by a continuous inspection program. The multifold objective of this research is to develop a methodology based on a direct Monte Carlo simulation process and to assess the reliability of aircraft structures. Initially, the structure is modeled as a parallel system with active redundancy comprised of elements with uncorrelated (statistically independent) strengths and subjected to an equal load distribution. Closed form expressions for the system capacity cumulative distribution function (CDF) are developed by expanding the current expression for the capacity CDF of a parallel system comprised by three elements to a parallel system comprised with up to six elements. These newly developed expressions will be used to check the accuracy of the implementation of a Monte Carlo simulation algorithm to determine the probability of failure of a parallel system comprised of an arbitrary number of statistically independent elements. The second objective of this work is to compute the probability of failure of a fuselage skin lap joint under static load conditions through a Monte Carlo simulation scheme by utilizing the residual strength of the fasteners subjected to various initial load distributions and then subjected to a new unequal load distribution resulting from subsequent fastener sequential failures. The final and main objective of this thesis is to present a methodology for computing the resulting gradual deterioration of the reliability of an aircraft structural component by employing a direct Monte Carlo simulation approach. The uncertainties associated with the time to crack initiation, the probability of crack detection, the exponent in the crack propagation rate (Paris equation) and the yield strength of the elements are considered in the analytical model. The structural component is assumed to consist of a prescribed number of elements. This Monte Carlo simulation methodology is used to determine the required non-periodic inspections so that the reliability of the structural component will not fall below a prescribed minimum level. A sensitivity analysis is conducted to determine the effect of three key parameters on the specification of the non-periodic inspection intervals: namely a parameter associated with the time to crack initiation, the applied nominal stress fluctuation and the minimum acceptable reliability level.

7 CFR 800.86 - Inspection of shiplot, unit train, and lash barge grain in single lots.

Code of Federal Regulations, 2010 CFR

2010-01-01

... prescribed in the instructions. (b) Application procedure. Applications for the official inspection of... statistical acceptance sampling and inspection plan according to the provisions of this section and procedures... inspection as part of a single lot and accepted by a statistical acceptance sampling and inspection plan...

Geographic Variation in Opioid Prescribing in the U.S.

PubMed Central

McDonald, Douglas C.; Carlson, Kenneth; Izrael, David

2012-01-01

Estimates of geographic variation among states and counties in the prevalence of opioid prescribing are developed using data from a large (135M) representative national sample of opioid prescriptions dispensed during 2008 by 37,000 retail pharmacies. Statistical analyses are used to estimate the extent to which county variation is explained by characteristics of resident populations, their healthcare utilization, proxy measures of morbidity, availability of healthcare resources, and prescription monitoring laws. Geographic variation in prevalence of prescribed opioids is large, greater than variation observed for other healthcare services. Counties having the highest prescribing rates for opioids were disproportionately located in Appalachia and in Southern and Western states. The number of available physicians was by far the strongest predictor of amounts prescribed, but only one-third of county variation is explained by the combination of all measured factors. Wide variation in prescribing opioids reflects weak consensus regarding the appropriate use of opioids for treating pain, especially chronic non-cancer pain. Patients’ demands for treatment have increased, more potent opioids have become available, an epidemic of abuse has emerged, and calls for increased government regulation are growing. Greater guidance, education and training in opioid prescribing are needed for clinicians to support appropriate prescribing practices. Perspective Wide geographic variation that does not reflect differences in the prevalence of injuries, surgeries, or conditions requiring analgesics raises questions about opioid prescribing practices. Low prescription rates may indicate under-treatment, while high rates may indicate overprescribing and insufficient attention to risks of misuse. PMID:23031398

The impact of drug samples on prescribing to the uninsured.

PubMed

Miller, David P; Mansfield, Richard J; Woods, Jonathan B; Wofford, James L; Moran, William P

2008-09-01

To determine whether drug samples are associated with physicians prescribing fewer generic, less costly medications. We conducted a retrospective study at a large university-affiliated internal medicine practice containing over 70 physicians. Using a pharmacy database, we identified all prescriptions written to uninsured or Medicaid patients that belonged to one of four classes of chronic medications. For the 9 months before and after the clinic closed its drug sample closet, we calculated the percentage of medications prescribed as generics and the mean cost of a 30-day supply of a prescription. Of 8911 prescriptions, 1973 met inclusion criteria. For uninsured patients, the percentage of medications prescribed as generics rose from 12% to 30% after the clinic closed its drug sample closet (P = 0.004). By consecutive three month periods, the percentage of prescribed generic medications rose steadily to a maximum of 40% (P < 0.001). For Medicaid patients, there was no significant change in generic prescribing (63% generic with samples versus 65% generic without samples, P = 0.42). Two factors were associated with generic prescribing in logistic regression: the absence of drug samples (OR 4.54, 95% CI 1.37-15.0) and the prescriber being an attending physician (OR 5.26, 95% CI 2.24-12.4). There was no statistically significant change in cost for either group. Physicians were three times more likely to prescribe generic medications to uninsured patients after drug samples were removed from the office. Drug samples may paradoxically lead to higher costs if physicians with access to samples prescribe more brand-name only drugs.

Knee Replacement: MedlinePlus Health Topic

MedlinePlus

... Surgery for a Total Knee System (BroadcastMed) - University Orthopedics Center, State College, PA, 8/21/2014 Statistics and Research Commonly Prescribed Blood Thinner Associated with Higher Risk ...

Influence of Qualification and Practice Settings of Dental Practitioners on Antimicrobial Prescribing in Delhi and National Capital Region, India

PubMed Central

Wasan, Himika; Gupta, Pooja; Mathur, Apoorva; Mutneja, Ekta; Mathur, Vijay Prakash; Gupta, Yogendra Kumar

2017-01-01

Background and Objectives: Inappropriate antimicrobial prescribing is highly reported in dentistry. The objective of the study was to see the effect of dental qualification and practice settings on antimicrobial prescribing practices among dental practitioners in Delhi and National Capital Region (NCR) of India. Materials and Methods: A self-designed and pretested questionnaire was given to 667 dental practitioners holding degrees of graduation, postgraduation, and those pursuing postgraduation, working in academic institutions and private clinics in NCR of India. Data were analyzed using statistical software Stata version 12.0. Chi-square and logistic regression tests were used for analysis. Results: Out of total 539 responded, 66.4% of the practitioners prescribed by brand name and 27.8% by generic name. Amoxicillin + clavulanic acid (27.4%) was the first choice. Only 26% of the practitioners asked for antimicrobial susceptibility testing. Space infections (91.9%), impacted third molar extractions (89.7%), and periodontal abscess (88.1%) were the conditions where antimicrobials were most frequently prescribed. However, 60.9% and 53.3% of the practitioners also prescribed antimicrobials for acute pulpitis and dry socket, respectively. For prophylaxis in medical conditions, amoxicillin was the first choice. In case of history of allergy to penicillin, 52.3% of the practitioners prescribe erythromycin whereas 14.6% prescribe amoxicillin. The adverse drug reporting culture was negligible, and only 14.3% of the practitioners were aware of the Pharmacovigilance Program of India. Level of qualification had a significant effect on prescribing (P < 0.05). Interpretation and Conclusion: Frequent irrational prescribing of antimicrobials used in odontogenic conditions warrants an urgent and continued need for guidelines as well as educational intervention programs in dentistry. This will improve the quality of antimicrobial prescribing practices in dentistry. PMID:28781493

Using spatial analysis to demonstrate the heterogeneity of the cardiovascular drug-prescribing pattern in Taiwan

PubMed Central

2011-01-01

Background Geographic Information Systems (GIS) combined with spatial analytical methods could be helpful in examining patterns of drug use. Little attention has been paid to geographic variation of cardiovascular prescription use in Taiwan. The main objective was to use local spatial association statistics to test whether or not the cardiovascular medication-prescribing pattern is homogenous across 352 townships in Taiwan. Methods The statistical methods used were the global measures of Moran's I and Local Indicators of Spatial Association (LISA). While Moran's I provides information on the overall spatial distribution of the data, LISA provides information on types of spatial association at the local level. LISA statistics can also be used to identify influential locations in spatial association analysis. The major classes of prescription cardiovascular drugs were taken from Taiwan's National Health Insurance Research Database (NHIRD), which has a coverage rate of over 97%. The dosage of each prescription was converted into defined daily doses to measure the consumption of each class of drugs. Data were analyzed with ArcGIS and GeoDa at the township level. Results The LISA statistics showed an unusual use of cardiovascular medications in the southern townships with high local variation. Patterns of drug use also showed more low-low spatial clusters (cold spots) than high-high spatial clusters (hot spots), and those low-low associations were clustered in the rural areas. Conclusions The cardiovascular drug prescribing patterns were heterogeneous across Taiwan. In particular, a clear pattern of north-south disparity exists. Such spatial clustering helps prioritize the target areas that require better education concerning drug use. PMID:21609462

Evaluation of rational drug use based on World Health Organization core drug use indicators in selected public hospitals of eastern Ethiopia: a cross sectional study.

PubMed

Sisay, Mekonnen; Mengistu, Getnet; Molla, Bereket; Amare, Firehiwot; Gabriel, Tesfaye

2017-02-23

Despite the complexity of drug use, a number of indicators have been developed, standardized and evaluated by the World Health Organization (WHO). These indicators are grouped in to three categories namely: prescribing indicators, patient care indicators and facility indicators. The study was aimed to evaluate rational drug use based on WHO-core drug use indicators in Dilchora referral hospital, Dire Dawa; Hiwot Fana specialized university hospital, Harar and Karamara general hospital, Jigjiga, eastern Ethiopia. Hospital based quantitative cross sectional study design was employed to evaluate rational drug use based on WHO core drug use indicators in selected hospitals. Systematic random sampling for prescribing indicators and convenient sampling for patient care indicators was employed. Taking WHO recommendations in to account, a total of 1,500 prescription papers (500 from each hospitals) were investigated. In each hospital, 200 outpatient attendants and 30 key essential drugs were also selected using the WHO recommendation. Data were collected using retrospective and prospective structured observational check list. Data were entered to EPI Data Version 3.1, exported and analyzed using SPSS version 16.0. Besides, the data were evaluated as per the WHO guidelines. Statistical significance was determined by one way analysis of variance (ANOVA) for some variables. P-value of less than 0.05 was considered statistically significant. Finally, tabular presentation was used to present the data. Mean, 2.34 (±1.08) drugs were prescribed in the selected hospitals. Prescriptions containing antibiotics and that of injectables were 57.87 and 10.9% respectively. The average consultation and dispensing time were 276.5 s and 61.12 s respectively. Besides, 75.77% of the prescribed drugs were actually dispensed. Only 3.3% of prescriptions were adequately labeled and 75.7% patients know about the dosage of the prescription. Not more than, 20(66.7%) key drugs were available in stock while only 19(63.3%) of key drugs had adequate labeling. On average, selected key drugs were out of stock for 30 days per year. All of the hospitals included in the study used the national drug list, formulary and standard treatment guidelines but none of them had their own drug list or guideline. Majority of WHO stated core drug use indicators were not met by the three hospitals included in the study.

Real world data of a veterinary teaching hospital in Japan: a pilot survey of prescribed medicines

PubMed Central

Tanaka, Noriko; Takizawa, Tsuyoshi; Miyamoto, Nao; Funayama, Shinji; Tanaka, Ryo; Okano, Syozo; Iwasaki, Toshio

2017-01-01

The prescription data from a digital accounting system of a veterinary teaching hospital collected between 2008 and 2011 in Japan were downloaded, stored in a database and analysed using a statistical analysis software, SAS. Seventy-six per cent of all prescriptions were drugs approved for human beings. The most frequently prescribed category was ‘Agents against pathogenic organisms’, such as antibiotics and chemotherapeutic agents, followed by ‘Cardiovascular agents’. Seventy-five per cent of prescribed oral formulations in the category ‘Agents against pathogenic organisms’ were drugs approved for human beings, while 78 per cent of the injectable prescriptions were those for veterinary. A total of 36 oral antipathogenic products were prescribed, and among them amoxicillin was prescribed the most, followed by cephalexin for human beings and enrofloxacin for veterinary. The pattern of cyclosporin prescription, which is the most prescribed product other than ‘Agents against pathogenic organisms’, was surveyed. The capsule formulation was primarily used for dogs, while oral solutions were preferably used for cats. This pilot study is the first analytical data of real prescription in hospitals in Japan and one of the longest surveys in veterinary world. PMID:29018532

Price regulation, new entry, and information shock on pharmaceutical market in Taiwan: a nationwide data-based study from 2001 to 2004

PubMed Central

2010-01-01

Background Using non-steroidal anti-inflammatory drugs (NSAIDs) as a case, we used Taiwan's National Health Insurance (NHI) database, to empirically explore the association between policy interventions (price regulation, new drug entry, and an information shock) and drug expenditures, utilization, and market structure between 2001 and 2004. Methods All NSAIDs prescribed in ambulatory visits in the NHI system during our study period were included and aggregated quarterly. Segmented regression analysis for interrupted time series was used to examine the associations between two price regulations, two new drug entries (cyclooxygennase-2 inhibitors) and the rofecoxib safety signal and expenditures and utilization of all NSAIDs. Herfindahl index (HHI) was applied to further examine the association between these interventions and market structure of NSAIDs. Results New entry was the only variable that was significantly correlated with changes of expenditures (positive change, p = 0.02) and market structure of the NSAIDs market in the NHI system. The correlation between price regulation (first price regulation, p = 0.62; second price regulation, p = 0.26) and information shock (p = 0.31) and drug expenditure were not statistically significant. There was no significant change in the prescribing volume of NSAIDs per rheumatoid arthritis (RA) or osteoarthritis (OA) ambulatory visit during the observational period. The market share of NSAIDs had also been largely substituted by these new drugs up to 50%, in a three-year period and resulted in a more concentrated market structure (HHI 0.17). Conclusions Our empirical study found that new drug entry was the main driving force behind escalating drug spending, especially by altering the market share. PMID:20653979

An Adaptive Buddy Check for Observational Quality Control

NASA Technical Reports Server (NTRS)

Dee, Dick P.; Rukhovets, Leonid; Todling, Ricardo; DaSilva, Arlindo M.; Larson, Jay W.; Einaudi, Franco (Technical Monitor)

2000-01-01

An adaptive buddy check algorithm is presented that adjusts tolerances for outlier observations based on the variability of surrounding data. The algorithm derives from a statistical hypothesis test combined with maximum-likelihood covariance estimation. Its stability is shown to depend on the initial identification of outliers by a simple background check. The adaptive feature ensures that the final quality control decisions are not very sensitive to prescribed statistics of first-guess and observation errors, nor on other approximations introduced into the algorithm. The implementation of the algorithm in a global atmospheric data assimilation is described. Its performance is contrasted with that of a non-adaptive buddy check, for the surface analysis of an extreme storm that took place in Europe on 27 December 1999. The adaptive algorithm allowed the inclusion of many important observations that differed greatly from the first guess and that would have been excluded on the basis of prescribed statistics. The analysis of the storm development was much improved as a result of these additional observations.

Intermediate time scale response of atmospheric CO 2 following prescribed fire in a longleaf pine forest

DOE Office of Scientific and Technical Information (OSTI.GOV)

Viner, Brian; Parker, M.; Maze, G.

Fire plays an essential role in maintaining the structure and function of longleaf pine ecosystems. While the effects of fire on carbon cycle have been measured in previous studies for short periods during a burn and for multiyear periods following the burn, information on how carbon cycle is influenced by such changes over the span of a few weeks to months has yet to be quantified. We have analyzed high-frequency measurements of CO 2 concentration and flux, as well as associated micrometeorological variables, at three levels of the tall Aiken AmeriFlux tower during and after a prescribed burn. Measurements ofmore » the CO 2 concentration and vertical fluxes were examined as well as calculated net ecosystem exchange (NEE) for periods prior to and after the burn. Large spikes in both CO 2 concentration and CO 2 flux during the fire and increases in atmospheric CO 2 concentration and reduced CO 2 flux were observed for several weeks following the burn, particularly below the forest canopy. Both CO 2 measurements and NEE were found to return to their preburn states within 60–90 days following the burn when no statistical significance was found between preburn and postburn NEE. Furthermore, this study examines the micrometeorological conditions during a low-intensity prescribed burn and its short-term effects on local CO 2 dynamics in a forested environment by identifying observable impacts on local measurements of atmospheric CO 2 concentration and fluxes.« less

Intermediate time scale response of atmospheric CO 2 following prescribed fire in a longleaf pine forest

DOE PAGES

Viner, Brian; Parker, M.; Maze, G.; ...

2016-10-12

Fire plays an essential role in maintaining the structure and function of longleaf pine ecosystems. While the effects of fire on carbon cycle have been measured in previous studies for short periods during a burn and for multiyear periods following the burn, information on how carbon cycle is influenced by such changes over the span of a few weeks to months has yet to be quantified. We have analyzed high-frequency measurements of CO 2 concentration and flux, as well as associated micrometeorological variables, at three levels of the tall Aiken AmeriFlux tower during and after a prescribed burn. Measurements ofmore » the CO 2 concentration and vertical fluxes were examined as well as calculated net ecosystem exchange (NEE) for periods prior to and after the burn. Large spikes in both CO 2 concentration and CO 2 flux during the fire and increases in atmospheric CO 2 concentration and reduced CO 2 flux were observed for several weeks following the burn, particularly below the forest canopy. Both CO 2 measurements and NEE were found to return to their preburn states within 60–90 days following the burn when no statistical significance was found between preburn and postburn NEE. Furthermore, this study examines the micrometeorological conditions during a low-intensity prescribed burn and its short-term effects on local CO 2 dynamics in a forested environment by identifying observable impacts on local measurements of atmospheric CO 2 concentration and fluxes.« less

Forb, Insect, and Soil Response to Burning and Mowing Wyoming Big Sagebrush in Greater Sage-Grouse Breeding Habitat

NASA Astrophysics Data System (ADS)

Hess, Jennifer E.; Beck, Jeffrey L.

2014-04-01

Wyoming big sagebrush ( Artemisia tridentata wyomingensis A. t. Nutt. ssp. wyomingensis Beetle and Young) communities provide structure and forbs and insects needed by greater sage-grouse ( Centrocercus urophasianus) for growth and survival. We evaluated forb, insect, and soil responses at six mowed and 19 prescribed burned sites compared to 25, paired and untreated reference sites. Sites were classified by treatment type, soil type, season, and decade of treatment (sites burned during 1990-1999 and sites burned or mowed during 2000-2006). Our objective was to evaluate differences in ten habitat attributes known to influence sage-grouse nesting and brood rearing to compare responses among treatment scenarios. Contrary to desired outcomes, treating Wyoming big sagebrush through prescribed burning or mowing may not stimulate cover or increase nutrition in food forbs, or increase insect abundance or indicators of soil quality compared with reference sites. In some cases, prescribed burning showed positive results compared with mowing such as greater forb crude protein content (%), ant (Hymenoptera; no./trap), beetle (Coleoptera/no./trap), and grasshopper abundance (Orthoptera; no./sweep), and total (%) soil carbon and nitrogen, but of these attributes, only grasshopper abundance was enhanced at burned sites compared with reference sites in 2008. Mowing did not promote a statistically significant increase in sage-grouse nesting or early brood-rearing habitat attributes such as cover or nutritional quality of food forbs, or counts of ants, beetles, or grasshoppers compared with reference sites.

Intermediate time scale response of atmospheric CO2 following prescribed fire in a longleaf pine forest

NASA Astrophysics Data System (ADS)

Viner, B.; Parker, M.; Maze, G.; Varnedoe, P.; Leclerc, M.; Starr, G.; Aubrey, D.; Zhang, G.; Duarte, H.

2016-10-01

Fire plays an essential role in maintaining the structure and function of longleaf pine ecosystems. While the effects of fire on carbon cycle have been measured in previous studies for short periods during a burn and for multiyear periods following the burn, information on how carbon cycle is influenced by such changes over the span of a few weeks to months has yet to be quantified. We have analyzed high-frequency measurements of CO2 concentration and flux, as well as associated micrometeorological variables, at three levels of the tall Aiken AmeriFlux tower during and after a prescribed burn. Measurements of the CO2 concentration and vertical fluxes were examined as well as calculated net ecosystem exchange (NEE) for periods prior to and after the burn. Large spikes in both CO2 concentration and CO2 flux during the fire and increases in atmospheric CO2 concentration and reduced CO2 flux were observed for several weeks following the burn, particularly below the forest canopy. Both CO2 measurements and NEE were found to return to their preburn states within 60-90 days following the burn when no statistical significance was found between preburn and postburn NEE. This study examines the micrometeorological conditions during a low-intensity prescribed burn and its short-term effects on local CO2 dynamics in a forested environment by identifying observable impacts on local measurements of atmospheric CO2 concentration and fluxes.

Forb, insect, and soil response to burning and mowing Wyoming big sagebrush in greater sage-grouse breeding habitat.

PubMed

Hess, Jennifer E; Beck, Jeffrey L

2014-04-01

Wyoming big sagebrush (Artemisia tridentata wyomingensis A. t. Nutt. ssp. wyomingensis Beetle and Young) communities provide structure and forbs and insects needed by greater sage-grouse (Centrocercus urophasianus) for growth and survival. We evaluated forb, insect, and soil responses at six mowed and 19 prescribed burned sites compared to 25, paired and untreated reference sites. Sites were classified by treatment type, soil type, season, and decade of treatment (sites burned during 1990-1999 and sites burned or mowed during 2000-2006). Our objective was to evaluate differences in ten habitat attributes known to influence sage-grouse nesting and brood rearing to compare responses among treatment scenarios. Contrary to desired outcomes, treating Wyoming big sagebrush through prescribed burning or mowing may not stimulate cover or increase nutrition in food forbs, or increase insect abundance or indicators of soil quality compared with reference sites. In some cases, prescribed burning showed positive results compared with mowing such as greater forb crude protein content (%), ant (Hymenoptera; no./trap), beetle (Coleoptera/no./trap), and grasshopper abundance (Orthoptera; no./sweep), and total (%) soil carbon and nitrogen, but of these attributes, only grasshopper abundance was enhanced at burned sites compared with reference sites in 2008. Mowing did not promote a statistically significant increase in sage-grouse nesting or early brood-rearing habitat attributes such as cover or nutritional quality of food forbs, or counts of ants, beetles, or grasshoppers compared with reference sites.

Tree injury and mortality in fires: developing process-based models

Treesearch

Bret W. Butler; Matthew B. Dickinson

2010-01-01

Wildland fire managers are often required to predict tree injury and mortality when planning a prescribed burn or when considering wildfire management options; and, currently, statistical models based on post-fire observations are the only tools available for this purpose. Implicit in the derivation of statistical models is the assumption that they are strictly...

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples. Volume 3: Structure and listing of programs

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

Prescribed fire applications in Forest and Woodlands: Integration of models and field studies to guide fire use

Treesearch

Kevin C. Ryan; Eric Rigolot; Francisco C. Rego; Herminio Botelho; Jose A. Vega; Paulo M. Fernandes; Tatiana M. Sofronova

2010-01-01

Globally prescribed burning is widely used for agro-forestry, restoration, and conservation to modify species composition and stand structure. Commonly stated goals of prescribed burns include to reduce hazardous fuels, improve species’ habitat, reduce the potential for severe fires in the wildland urban interface or protect municipal watersheds. Treatments may focus...

Fire tolerance of a resprouting Artemisia (Asteraceae) shrub

USGS Publications Warehouse

Winter, S.L.; Fuhlendorf, S.D.; Goad, C.L.; Davis, C.A.; Hickman, K.R.; Leslie, David M.

2011-01-01

In North America, most Artemisia (Asteraceae) shrub species lack the ability to resprout after disturbances that remove aboveground biomass. We studied the response of one of the few resprouting Artemisia shrubs, Artemisia filifolia (sand sagebrush), to the effects of prescribed fires. We collected data on A. filifolia density and structural characteristics (height, canopy area, and canopy volume) in an A. filifolia shrubland in the southern Great Plains of North America. Our study sites included areas that had not been treated with prescribed fire, areas that had been treated with only one prescribed fire within the previous 5 years, and areas that had been treated with two prescribed fires within the previous 10 years. Our data were collected at time periods ranging from 1/2 to 5 years after the prescribed fires. Density of A. filifolia was not affected by one or two fires. Structural characteristics, although initially altered by prescribed fire, recovered to levels characteristic of unburned areas in 3-4 years after those fires. In contrast to most non-sprouting North American Artemisia shrub species, our research suggested that the resprouting A. filifolia is highly tolerant to the effects of fire. ?? 2011 Springer Science+Business Media B.V.

Long-term impacts of prescribed fire on stand structure, growth, mortality, and individual tree vigor in Pinus resinosa forests

Treesearch

Sawyer S. Scherer; Anthony W. D' Amato; Christel C. Kern; Brian J. Palik; Matthew B. Russell

2016-01-01

Prescribed fire is increasingly being viewed as a valuable tool for mitigating the ecological consequences of long-term fire suppression within fire-adapted forest ecosystems. While the use of burning treatments in northern temperate conifer forests has at times received considerable attention, the long-term (>10 years) effects on forest structure and...

Effects of fire frequency on long-term development of an oak-hickory forest in Missouri, U.S.A.

Treesearch

Benjamin O. Knapp; Michael A. Hullinger; John M. Kabrick

2017-01-01

Repeated prescribed burning over long timescales has some predictable effects on forest structure and composition, but multi-decadal patterns of stand dynamics and successional change with different fire frequencies have rarely been described. We used longitudinal data from a prescribed burning study conducted over a 63-year period to quantify stand structure (stem...

Response of ground-dwelling spider assemblages to prescribed fire following stand structure manipulation in the southern Cascade Range

Treesearch

Nancy E. Gillette; Richard S. Vetter; Sylvia R. Mori; Carline R. Rudolph; Dessa R. Welty

2008-01-01

We assessed spider (Arachnida: Araneae) responses to prescribed fire following stand s tructure treatments in ponderosa pine (Pinus ponderosa Dougl. ex P. & C. Laws.) stands in the Cascade Range of California. Stands were logged or left untreated to create three levels of structural diversity. We logged one treatment to minimize old-growth...

Vegetation Recovery and Stand Structure Following a Prescribed Stand-Replacement Burn in Sand Pine Scrub

Treesearch

Cathryn H. Greenberg

2003-01-01

Vegetation and stand structure of sand pine scrub in central Florida, USA, were measured before a prescribed stand-replacement burn and for > 8 y afterward. Herbaceous species richness peaked within 16 months postburn, then gradually declined, although significant differences were detected only between 16 months and > 8 y postburn. Twenty-two plant species...

Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis.

PubMed

Dalton, Kieran; O'Brien, Gary; O'Mahony, Denis; Byrne, Stephen

2018-06-08

computerised interventions have been suggested as an effective strategy to reduce potentially inappropriate prescribing (PIP) for hospitalised older adults. This systematic review and meta-analysis examined the evidence for efficacy of computerised interventions designed to reduce PIP in this patient group. an electronic literature search was conducted using eight databases up to October 2017. Included studies were controlled trials of computerised interventions aiming to reduce PIP in hospitalised older adults (≥65 years). Risk of bias was assessed using Cochrane's Effective Practice and Organisation of Care criteria. of 653 records identified, eight studies were included-two randomised controlled trials, two interrupted time series analysis studies and four controlled before-after studies. Included studies were mostly at a low risk of bias. Overall, seven studies showed either a statistically significant reduction in the proportion of patients prescribed a potentially inappropriate medicine (PIM) (absolute risk reduction {ARR} 1.3-30.1%), or in PIMs ordered (ARR 2-5.9%). However, there is insufficient evidence thus far to suggest that these interventions can routinely improve patient-related outcomes. It was only possible to include three studies in the meta-analysis-which demonstrated that intervention patients were less likely to be prescribed a PIM (odds ratio 0.6; 95% CI 0.38, 0.93). No computerised intervention targeting potential prescribing omissions (PPOs) was identified. this systematic review concludes that computerised interventions are capable of statistically significantly reducing PIMs in hospitalised older adults. Future interventions should strive to target both PIMs and PPOs, ideally demonstrating both cost-effectiveness data and clinically significant improvements in patient-related outcomes.

Prescribing pattern of analgesics in orthopedic in-patient department at tertiary care hospital in Guwahati, Assam, Northeast India

PubMed Central

Choudhury, Dwijen Kumar; Bezbaruah, Babul Kumar

2016-01-01

Objectives: The aim of this study is to evaluate the prescribing pattern of analgesics and analyze the rational use of analgesic in orthopedic in-patient department of tertiary care teaching hospital, Guwahati, Assam. Subjects and Methods: An observational and cross-sectional study was carried out for 1 month from April to May 2014. Collected data included age, sex, diagnosis and line of management during the study. The generic name and the average cost of treatment per patient were evaluated using Indian Drug Review, 2014. The prescribed drugs were assessed with respective National Model List of Essential Medicines (NLEM), 2011 and the rationality of prescriptions was determined using the World Health Organization indicators of drug utilization. The patients’ details were recorded in a predeigned data collection form and results were analyzed by descriptive statistics. Results: Out of 200 patients, 123 were male and 77 were female. The average number of analgesic per prescription was 1.46. In this study, 55.5% of patients had received single analgesic. Diclofenac was the most commonly prescribed analgesic (43.49%). During hospitalization, majority of the patients have received parenteral preparation. Gastroprotective agents and antimicrobials were frequently prescribed along with analgesics. Out of 292 analgesics prescribed, 183 (62.67%) were from the NLEM, India. Furthermore, 176 (57.19%) analgesics were prescribed by generic name. The average cost of treatment per patient was 2151.72 INR. Utilization of analgesic in terms of defined daily dose/100 bed-days was 104.01. Conclusion: The percentages of analgesics prescribing from NLEM and the use of analgesic by generic name were found satisfactory. Regular educational interventions to improve prescribing practices among physicians at different levels may further promote rational prescribing. PMID:27756947

A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy.

PubMed

Naughton, Corina; Feely, John; Bennett, Kathleen

2007-10-01

Interventions to promote prescribing of preventive therapies in patients with cardiovascular disease (CVD) or diabetes have reported variable success. (i) To evaluate the effect of prescribing feedback on GP practice using academic detailing compared to postal bulletin on prescribing of CVD preventive therapies in patients with CVD or diabetes at 3 and 6 months post intervention and (ii) to evaluate the intervention from a GP's perspective. Volunteer GP practices (n = 98) were randomized to receive individualized prescribing feedback via academic detailing (postal bulletin plus outreach visit) (n = 48) or postal bulletin (n = 50). The proportion of CVD or diabetic patients on statins and antiplatelet agents/warfarin pre- and post-intervention was calculated for each GP practice. Multivariate regression with a random effects model was used to compare differences between the groups adjusting for GP clustering and confounding factors. beta-Coefficients and 95% confidence intervals (CIs) are presented. There was a 3% increase in statin prescribing in CVD patients at 6 months post-intervention for both randomized groups, but there was no statistical difference between the groups (beta = 0.004; 95% CI = -0.01 to 0.02). Statin and antiplatelet/warfarin prescribing also increased in the diabetic population; there was no significant differences between the groups. GPs participating in the project expressed a high level of satisfaction with both interventions. Prescribing of preventive therapies increased in both randomized groups over the study period. But academic detailing did not have an additional effect on changing prescribing over the postal bulletin alone.

Differences in quality standards when prescribing nutritional support: Differences between specialist and non-specialist physicians.

PubMed

Morán López, Jesús Manuel; Piedra León, María; Enciso Izquierdo, Fidel Jesús; Luengo Pérez, Luis Miguel; Amado Señaris, José Antonio

2016-01-01

Adequate nutritional support includes many different aspects, but poor understanding of clinical nutrition by health care professionales often results in an inadequate prescription. A study was conducted to compare enteral and parenteral nutritional support plans prescribed by specialist and non-specialist physicians. Non-specialist physicians recorded anthropometric data from only 13.3% of patients, and none of them performed nutritional assessments. Protein amounts provided by non-specialist physicians were lower than estimated based on ESPEN (10.29g of nitrogen vs 14.62; P<.001). Differences were not statistically significant in the specialist group (14.88g of nitrogen; P=.072). Calorie and glutamine provision and laboratory controls prescribed by specialists were significantly closer to those recommended by clinical guidelines. Nutritional support prescribed by specialists in endocrinology and nutrition at San Pedro de Alcántara Hospital was closer to clinical practice guideline standards and of higher quality as compared to that prescribed by non-specialists. Copyright © 2015 SEEN. Published by Elsevier España, S.L.U. All rights reserved.

Survival of the endangered Pima pineapple cactus: Does clearing before prescribed fire alter survival postfire?

USGS Publications Warehouse

Thomas, Kathryn A.; Jarchow, Christopher; Crawford, Julie A.

2017-01-01

Federal land managers and ranchers often use prescribed fire as a tool to reduce invading woody plants within desert grasslands of the arid southwestern United States. Managers must evaluate the threat of the burn toward the health and survival of plants of concern including how preemptive clearing before prescribed fire might benefit these species. One example is the endangered Pima pineapple cactus (Coryphantha scheeri var. robustispina), a small hemispheric cactus of desert scrublands and grasslands of south-central Arizona and northern Sonora, Mexico. In 2014, we examined survival of Pima pineapple cactus documented in 2009 or 2010 within grasslands of Buenos Aires National Wildlife Refuge in Arizona. Of the 72 sites observed, 35 had no burn after documentation and 37 experienced prescribed fire. Refuge staff removed vegetation between 0.3 and 3.0 m from the cactus preburn. We found that Pima pineapple cacti in areas subjected to prescribed fire and with preemptive clearing had the same survival statistically as cacti from sites that were not burned.

Prokinetics prescribing in paediatrics: evidence on cisapride, domperidone, and metoclopramide.

PubMed

Mt-Isa, Shahrul; Tomlin, Stephen; Sutcliffe, Alastair; Underwood, Martin; Williamson, Paula; Croft, Nicholas M; Ashby, Deborah

2015-04-01

Domperidone and metoclopramide are prokinetics commonly prescribed off-label to infants and younger children in an attempt to treat gastro-oesophageal reflux symptoms. Another prokinetic drug, cisapride, was used but withdrawn in 2000 in the United Kingdom because of serious arrhythmic adverse events. Medicines and Healthcare Products Regulatory Agency issued safety warnings for domperidone in May 2012 and restricted its indications. We report here national primary care prescribing trends and safety signals of these drugs in children. We used data from the General Practice Research Database between 1990 and 2006 for children <18 years. Descriptive statistics and Poisson regressions were performed to characterise prescribing trends. We examined safety signals in nested case-control studies. The proportion of children <2 years old being prescribed one of the medications doubled during the study period. Prescriptions of domperidone increased 10-fold, mainly following the withdrawal of cisapride in 2000. Prescriptions of metoclopramide did not change significantly. Despite the increase in prescriptions of domperidone, no new safety signals were identified. These data showed dramatic changes in prescribing of cisapride and domperidone despite the lack of good-quality supporting evidence. It is possible that these prescribing trends were influenced by published guidelines. Even if produced without robust efficacy and safety evidence, published guidelines can influence clinicians and consequently affect prescribing. Therefore, improving the evidence base on prokinetics to inform future guidelines is vital. The lack of new safety signals during this period would support the development of suitable powered clinical studies.

The prescribing practices of nurses who care for patients with skin conditions: a questionnaire survey.

PubMed

Carey, Nicola; Courtenay, Molly; Stenner, Karen

2013-07-01

To explore the practice of nurses who prescribe medication for patients with skin conditions. Nurses have lead roles in dermatology services. In the United Kingdom, nurses in primary care frequently prescribe medicines for skin conditions, but there are concerns about role preparation and access to continuing professional development. The prescribing practices of nurse independent supplementary prescribers who care for patients with skin conditions are under-researched. Cross-sectional survey. An online questionnaire was used to survey 186 nurses who prescribed for skin conditions from May-July 2010. Data were analysed using descriptive statistics and nonparametric tests. The majority worked in primary care (78%) and general practice (111, 59.7%). Twenty (10.8%) had specialist modules (at diploma, degree or master's level), 104 (55.9%) had dermatology training (e.g. study days), 44 (23.7%) had no training, and a further 18 (9.6%) did not respond. Oral antibiotics, topical antifungal and antibacterial drugs were frequently prescribed. Nurses with specialist dermatology training used their qualification in a greater number of ways, prescribed the broadest range of products and prescribed more items per week. Over 70% reporting on continuing professional development had been able to access it. A large number of nurses in primary care prescribe medicines for skin conditions and are involved in medicines management activities. Lack of specialist dermatology training is a concern and associated with lower prescribing-related activities. Access to dermatology training and continuing professional development are required to support nurse development in this area of practice and maximise benefits. Nurse prescribers' involvement in medicines management activities has important implications in terms of improving access to services, efficiency and cost savings. To maximise their contribution, improved provision of specialist dermatology training is required. This will be of interest to education providers and service planners in the UK and countries around the world. © 2013 John Wiley & Sons Ltd.

Analytical prediction of the interior noise for cylindrical models of aircraft fuselages for prescribed exterior noise fields. Phase 2: Models for sidewall trim, stiffened structures and cabin acoustics with floor partition

NASA Technical Reports Server (NTRS)

Pope, L. D.; Wilby, E. G.

1982-01-01

An airplane interior noise prediction model is developed to determine the important parameters associated with sound transmission into the interiors of airplanes, and to identify apropriate noise control methods. Models for stiffened structures, and cabin acoustics with floor partition are developed. Validation studies are undertaken using three test articles: a ring stringer stiffened cylinder, an unstiffened cylinder with floor partition, and ring stringer stiffened cylinder with floor partition and sidewall trim. The noise reductions of the three test articles are computed using the heoretical models and compared to measured values. A statistical analysis of the comparison data indicates that there is no bias in the predictions although a substantial random error exists so that a discrepancy of more than five or six dB can be expected for about one out of three predictions.

Changes in downed wood and forest structure after prescribed fire in ponderosa pine forests

Treesearch

Victoria Saab; Lisa Bate; John Lehmkuhl; Brett Dickson; Scott Story; Stephanie Jentsch; William Block

2006-01-01

Most prescribed fire plans focus on reducing wildfire hazards with little consideration given to effects on wildlife populations and their habitats. To evaluate effectiveness of prescribed burning in reducing fuels and to assess effects of fuels reduction on wildlife, we began a large-scale study known as the Birds and Burns Network in 2002. In this paper we analyze...

Response of forest soil Acari to prescribed fire following stand structure manipulation in the southern Cascade Range.Can

Treesearch

Michael A. Camann; Nancy E. Gillette; Karen L. Lamoncha; Sylvia R. Mori

2008-01-01

We studied responses of Acari, especially oribatid mites, to prescribed low-intensity fire in an east side pine site in the southern Cascade Range in California. We compared oribatid population and assemblage responses to prescribed fire in stands that had been selectively logged to enhance old growth characteristics, in logged stands to minimize old growth...

Yellow pine regeneration as a function of fire severity and post-burn stand structure in the southern Appalachian Mountains

Treesearch

Michael A. Jenkins; Robert N. Klein; Virginia L. McDaniel

2011-01-01

We used pre- and post-burn fire effects data from six prescribed burns to examine post-burn threshold effects of stand structure (understory density, overstory density, shrub cover, duff depth, and total fuel load) on the regeneration of yellow pine (Pinus subgenus Diploxylon) seedlings and cover of herbaceous vegetation in six prescribed-fire management units located...

The Use of Silviculture and Prescribed Fire to Manage Stand Structure and Fuel Profiles in a Multi-aged Lodgepole Pine Forest

Treesearch

Colin C. Hardy; Helen Y. Smith; Ward McCaughey

2006-01-01

This paper presents several components of a multi-disciplinary project designed to evaluate the ecological and biological effects of two innovative silvicultural treatments coupled with prescribed fire in an attempt to both manage fuel profiles and create two-aged stand structures in lodgepole pine. Two shelterwood silvicultural treatments were designed to replicate as...

Determinants associated with veterinary antimicrobial prescribing in farm animals in the Netherlands: a qualitative study.

PubMed

Speksnijder, D C; Jaarsma, A D C; van der Gugten, A C; Verheij, T J M; Wagenaar, J A

2015-04-01

Antimicrobial use in farm animals might contribute to the development of antimicrobial resistance in humans and animals, and there is an urgent need to reduce antimicrobial use in farm animals. Veterinarians are typically responsible for prescribing and overseeing antimicrobial use in animals. A thorough understanding of veterinarians' current prescribing practices and their reasons to prescribe antimicrobials might offer leads for interventions to reduce antimicrobial use in farm animals. This paper presents the results of a qualitative study of factors that influence prescribing behaviour of farm animal veterinarians. Semi-structured interviews with eleven farm animal veterinarians were conducted, which were taped, transcribed and iteratively analysed. This preliminary analysis was further discussed and refined in an expert meeting. A final conceptual model was derived from the analysis and sent to all the respondents for validation. Many conflicting interests are identifiable when it comes to antimicrobial prescribing by farm animal veterinarians. Belief in the professional obligation to alleviate animal suffering, financial dependency on clients, risk avoidance, shortcomings in advisory skills, financial barriers for structural veterinary herd health advisory services, lack of farmers' compliance to veterinary recommendations, public health interests, personal beliefs regarding the veterinary contribution to antimicrobial resistance and major economic powers are all influential determinants in antimicrobial prescribing behaviour of farm animal veterinarians. Interventions to change prescribing behaviour of farm animal veterinarians could address attitudes and advisory skills of veterinarians, as well as provide tools to deal with (perceived) pressure from farmers and advisors to prescribe antimicrobials. Additional (policy) measures could probably support farm animal veterinarians in acting as a more independent animal health consultant. © 2014 Blackwell Verlag GmbH.

Antidepressant prescribing and changes in antidepressant poisoning mortality and suicide in England, 1993-2004.

PubMed

Morgan, Oliver; Griffiths, Clare; Majeed, Azeem

2008-03-01

In England, the impact of increased use of antidepressant medications is unclear. We examine associations between antidepressant use, suicide and antidepressant poisoning mortality, adjusted for important covariates. Data on suicide and antidepressant poisoning mortality were provided by the Office for National Statistics. Prescription data were provided by the Department of Health. Age- and sex-specific prescribing rates were estimated from The Health Improvement Network primary care data. We measured the association between prescribing, suicide and poisoning mortality after adjusting for age, sex, calendar year, prescribing rates and use of newer antidepressants drugs. The prevalence of antidepressant treatment increased during the 1990s for all age and sex groups. Treatment prevalence remained constant from 2002 but declined among children and adolescents. Between 1993 and 2004, age-standardized rates for suicide decreased from 98.2 to 81.3 per million populations and for antidepressants from 9.2 to 7.4 per million populations. Before adjustment, increased antidepressant prescribing was associated with a decrease in suicide (r(s) = -0.90, P < 0.001) and antidepressant poisoning mortality rates (r(s) = -0.65, P = 0.023). This association disappeared after adjustment. In England, at a population level, there does not appear to be an association between antidepressant prescribing and antidepressant poisoning mortality or suicide.

Prescribing Patterns of Drugs in Acute Respiratory Distress Syndrome (ARDS): An Observational Study

PubMed Central

Rao, Shobitha; Chogtu, Bharti

2015-01-01

Introduction: Acute respiratory distress syndrome (ARDS) is characterized by acute respiratory failure and is associated with wide range of clinical disorders. Controversy prevails over the pharmacological intervention in this disease. The aim of the study was to observe the prescribing pattern of drugs in patients with ARDS managed at a tertiary care hospital. Materials and Methods: This observational study was conducted at tertiary care hospital in India. Data of patients admitted from January 2010 to December 2012 was collected. Patients aged more than 18 years admitted in ICU, who were diagnosed to have ARDS during the study period, were included. A total of 150 patients of ARDS were selected. Data was collected as per the pre designed proforma and it included patients’ age, gender, clinical disorders precipitating ARDS, prescribing pattern of drugs and outcome. The data of the subjects was collected till discharge from hospital or death. Results: Infection was the cause of ARDS in 81.3% (n=122) of subjects. Antibiotics were prescribed in all the subjects and beta-lactams were prescribed in 97.3% (n=146). 41.3% (n=62) were prescribed corticosteroids, 39.3% (n=59) diuretics and 89.3% (n=134) intravenous fluids. Conclusion: The outcome of patients on different pharmacological treatment did not show any statistically significant difference. PMID:25859465

The safe implementation of a prison-based methadone maintenance programme: 7 year time-series analysis of primary care prescribing data

PubMed Central

2014-01-01

Background Internationally there is policy support for the introduction of methadone maintenance programmes into prison settings. Increasingly GPs are encouraged to undertake this work although concerns remain regarding the safety of such programmes. This study sought to evaluate the impact and safety of the introduction of a general practitioner with a special interest (GPsi) in substance misuse led methadone prescribing service into a UK prison between 2003 and 2010. Methods Time series analysis of secondary prescribing data pertaining to opiate maintenance therapies, opiate detoxification therapies and opiate related deaths for the time period 2003 to 2010. Results Results show that following introduction of a GPsi in substance misuse there was a statistically significant increase in both methadone maintenance and detoxification treatments. Over time the rate of methadone maintenance prescribing plateaued with a corresponding decrease in the rate of methadone detoxification prescribing. There were no methadone related deaths in prison over the study period. Conclusion The phased introduction of opiate replacement therapies into a busy remand prison did not result in any deaths within the prison for which opiate replacement was identified as the cause. GPsi led opiate prescribing programmes can be introduced safely into secure environments. PMID:24712316

Teaching Prescribing: Just What the Doctor Ordered? A Thematic Analysis of the Views of Newly Qualified Doctors

PubMed Central

Hansen, Christina R.; Walsh, Elaine K.; Bradley, Colin P.; Sahm, Laura J.

2017-01-01

Undergraduate medical education has been criticised for failing to adequately prepare doctors for the task of prescribing. Pharmacists have been shown to improve medication use in hospitals. This study aims to elicit the views of intern doctors on the challenges of prescribing, and to suggest changes in education to enhance prescribing practice and potential role of the pharmacist. Semi-structured, qualitative interviews were conducted with intern doctors in their first year post qualification in an Irish hospital. Data collection was conducted until no new themes emerged and thematic analysis was performed. Thirteen interviews took place. Interns described training in practical prescribing as limited and felt the curriculum failed to convey the reality of actual prescribing. Pharmacists were perceived to be a useful, but underutilised, information source in the prescribing process. They requested an earlier introduction, and repeated exposure, to prescribing, and suggested the involvement of peers and pharmacists in this teaching. Intern doctors reported difficulties in applying knowledge gained in medical school to clinical practice. New strategies are needed to enhance the clinical relevance of the medical curriculum by rethinking the learning outcomes regarding prescribing practice and the involvement of pharmacists in prescribing education. PMID:28970444

Quantifying the use of the statin antilipemic drugs: comparisons and contrasts between Nova Scotia, Canada, and Queensland, Australia.

PubMed

Cooke, Charmaine; Nissen, Lisa; Sketris, Ingrid; Tett, Susan E

2005-04-01

Jurisdictions are developing public drug insurance systems to improve access to pharmaceuticals, cost-effective prescribing, and patient health and well-being. We compared 2 jurisdictions with different pharmaceutical policies to determine prescribing patterns for 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (ie, statins). The aim of this work was to investigate the feasibility of using available prescription administrative databases to compare the use of statins in Queensland, Australia, and in Nova Scotia, Canada. Data from the Nova Scotia Pharmacare Program and the Health Insurance Commission in Australia were used to obtain dispensing data. Utilization was compared for the 5-year period from 1997 through 2001, using the World Health Organization anatomic therapeutic chemical/defined daily dose (DDD) system. In the year 2001, there were 177,000 beneficiaries in the public drug plan in Nova Scotia (62% aged > or = 65 years old) and 960,000 concession beneficiaries (pensioners and social security recipients, 61 aged > or = 65 years) in Queensland. These 2 groups were comparable. The overall utilization of statin medications increased steadily in both areas over the study period, from 50 to 205 DDD/1000 beneficiaries per day. Comparison of the 2 growth lines showed no statistically significant differences in overall statin use despite differences in brand availabilities and policies about prescribing. In the year 2001, atorvastatin was the most commonly prescribed statin in both areas, comprising 46% of statin use in Nova Scotia and 51% in Queensland. Mean doses of each statin prescribed were slightly above the DDDs. Expenditure on statins per 1000 beneficiaries and per DDD were similar in each jurisdiction, being slightly higher in Nova Scotia. Despite differences in pharmaceutical reimbursement systems, use of the statins was similar in Nova Scotia and Queensland. The feasibility of the methodology was demonstrated. Future studies, including comparisons of drug utilization for other classes of drugs for which drug policies may be divergent (eg, different pricing structures or prior authorization requirements), or for which less evidence for appropriate use is available, may be useful.

Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis.

PubMed

Chang, Hsien-Yen; Lyapustina, Tatyana; Rutkow, Lainie; Daubresse, Matthew; Richey, Matt; Faul, Mark; Stuart, Elizabeth A; Alexander, G Caleb

2016-08-01

Prescription drug monitoring programs (PDMPs) and pill mill laws were implemented to reduce opioid-related injuries/deaths. We evaluated their effects on high-risk prescribers in Florida. We used IMS Health's LRx Lifelink database between July 2010 and September 2012 to identify opioid-prescribing prescribers in Florida (intervention state, N: 38,465) and Georgia (control state, N: 18,566). The pre-intervention, intervention, and post-intervention periods were: July 2010-June 2011, July 2011-September 2011, and October 2011-September 2012. High-risk prescribers were those in the top 5th percentile of opioid volume during four consecutive calendar quarters. We applied comparative interrupted time series models to evaluate policy effects on clinical practices and monthly prescribing measures for low-risk/high-risk prescribers. We identified 1526 (4.0%) high-risk prescribers in Florida, accounting for 67% of total opioid volume and 40% of total opioid prescriptions. Relative to their lower-risk counterparts, they wrote sixteen times more monthly opioid prescriptions (79 vs. 5, p<0.01), and had more prescription-filling patients receiving opioids (47% vs. 19%, p<0.01). Following policy implementation, Florida's high-risk providers experienced large relative reductions in opioid patients and opioid prescriptions (-536 patients/month, 95% confidence intervals [CI] -829 to -243; -847 prescriptions/month, CI -1498 to -197), morphine equivalent dose (-0.88mg/month, CI -1.13 to -0.62), and total opioid volume (-3.88kg/month, CI -5.14 to -2.62). Low-risk providers did not experience statistically significantly relative reductions, nor did policy implementation affect the status of being high- vs. low- risk prescribers. High-risk prescribers are disproportionately responsive to state policies. However, opioids-prescribing remains highly concentrated among high-risk providers. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Short- and long-term effects on fuels, forest structure, and wildfire potential from prescribed fire and resource benefit fire in southwestern forests, USA

Treesearch

Molly E. Hunter; Jose M. Iniguez; Leigh B. Lentile

2011-01-01

Prescribed and resource benefit fires are used to manage fuels in fire-prone landscapes in the Southwest. These practices, however, typically occur under different conditions, potentially leading to differences in fire behavior and effects. The objectives of this study were to investigate the effects of recent prescribed fires, resource benefit fires, and repeated...

Basidiomycete fungal communities in Australian sclerophyll forest soil are altered by repeated prescribed burning.

PubMed

Anderson, Ian C; Bastias, Brigitte A; Genney, David R; Parkin, Pamela I; Cairney, John W G

2007-04-01

Soil basidiomycetes play key roles in forest nutrient and carbon cycling processes, yet the diversity and structure of below ground basidiomycete communities remain poorly understood. Prescribed burning is a commonly used forest management practice and there is evidence that single fire events can have an impact on soil fungal communities but little is known about the effects of repeated prescribed burning. We have used internal transcribed spacer (ITS) terminal restriction fragment length polymorphism (T-RFLP) analysis to investigate the impacts of repeated prescribed burning every two or four years over a period of 30 years on soil basidiomycete communities in an Australian wet sclerophyll forest. Detrended correspondence analysis of ITS T-RFLP profiles separated basidiomycete communities in unburned control plots from those in burned plots, with those burned every two years being the most different from controls. Burning had no effect on basidiomycete species richness, thus these differences appear to be due to changes in community structure. Basidiomycete communities in the unburned control plots were vertically stratified in the upper 20 cm of soil, but no evidence was found for stratification in the burned plots, suggesting that repeated prescribed burning results in more uniform basidiomycete communities. Overall, the results demonstrate that repeated prescribed burning alters soil basidiomycete communities, with the effect being greater with more frequent burning.

Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States.

PubMed

Durkin, Michael J; Feng, Qianxi; Warren, Kyle; Lockhart, Peter B; Thornhill, Martin H; Munshi, Kiraat D; Henderson, Rochelle R; Hsueh, Kevin; Fraser, Victoria J

2018-05-01

The purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States. We used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription. Overall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001). Overall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time. From these authors' definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists. Copyright © 2018 American Dental Association. Published by Elsevier Inc. All rights reserved.

Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report of a National Survey.

PubMed

Germack, Mark; Sedgley, Christine M; Sabbah, Wael; Whitten, Brian

2017-10-01

This study surveyed the antibiotic prescribing practices of endodontists, and data were compared with previous surveys conducted in 1994 and 1999. A 17-question survey was sent via www.surveymonkey.com to 3000 active members of the American Association of Endodontists for responses about antibiotic prescribing practices and demographics. The data were analyzed using descriptive statistics, chi-square tests, and linear regression analyses. Six hundred eighty-six participants (22.86%) completed the survey. The most frequently prescribed antibiotics were amoxicillin (60.71%) followed by penicillin V (30.43%) and clindamycin for patients with allergies (95.4%). Respondents reported prescribing antibiotics for irreversible pulpitis with mild symptoms (1.75%), irreversible pulpitis with moderate symptoms (6.41%), necrotic pulp with symptomatic apical periodontitis (43.59%), chronic apical abscess without (10.50%) or with symptoms (29.74%), acute apical abscess (95.92%), avulsion (70.26%), endodontic surgery (41.69%), retreatment (silver point [23.76%] or gutta-percha [15.60%]), postoperative pain after instrumentation or obturation (12.39%), and perforation repair (5.98%). The type of practice (solo/group) and geographic region (Southeast) were significant predictors of increased antibiotic prescribing; 36.89% of respondents reported prescribing antibiotics that are not necessary, most commonly because of patient expectations. Since 1999, there has been a significant shift from prescribing penicillin V to amoxicillin as endodontists' first choice of antibiotic and a significant increase in the use of clindamycin for penicillin-allergic patients. Antibiotics continue to be prescribed in clinical situations for which they are typically not indicated, most commonly because of patient expectations. Regional differences in antibiotic prescribing practices by endodontists exist in the United States. Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

The impact of a general practice group intervention on prescribing costs and patterns.

PubMed Central

Walker, Jane; Mathers, Nigel

2002-01-01

BACKGROUND: The formation of primary care groups (PCGs) and trusts (PCTs) has shifted the emphasis from individual practice initiatives to group-based efforts to control rising prescribing costs. However, there is a paucity of literature describing such group initiatives. We report the results of a multilevel group initiative, involving input from a pharmaceutical adviser, practice comparison feedback, and peer review meetings. AIM: To determine the impact of a prescribing initiative on the prescribing patterns of a group of general practices. DESIGN OF STUDY: A comparative study with non-matched controls. SETTING: Nine semi-rural/rural practices forming a commissioning group pilot, later a PCG, in Southern Derbyshire with nine practices as controls. METHOD: Practice data were collated for overall prescribing and for therapeutic categories, between the years 1997/1998 and 1998/1999 and analysed statistically. Prescribing expenditure trends were also collated. RESULTS: Although both groups came well within their prescribing budgets, in the study group this was for the first time in five years. Their rate of increase in expenditure slowed significantly following the initiative compared with that of the comparison group, which continued to rise (median practice net ingredient cost/patient unit (nic/PU) increase: Pound Sterling0.69 and Pound Sterling3.80 respectively; P = 0.03). The study group's nic/PU dropped below, and stayed below, that of the comparison group one month after the start of the initiative. For most therapeutic categories the study group had lower increases in costs and higher increases in percentage of generic items than the comparison group. Quality markers were unaffected. CONCLUSION: We suggest that practices with diverse prescribing patterns can work together effectively within a PCT locality to control prescribing costs. PMID:12030659

Barriers to electronic prescribing: Nebraska pharmacists' perspective.

PubMed

Lander, Lina; Klepser, Donald G; Cochran, Gary L; Lomelin, Daniel E; Morien, Marsha

2013-01-01

Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria. We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants' responses. Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing. The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted. © 2012 National Rural Health Association.

Functionally Graded Designer Viscoelastic Materials Tailored to Perform Prescribed Tasks with Probabilistic Failures and Lifetimes

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hilton, Harry H.

Protocols are developed for formulating optimal viscoelastic designer functionally graded materials tailored to best respond to prescribed loading and boundary conditions. In essence, an inverse approach is adopted where material properties instead of structures per se are designed and then distributed throughout structural elements. The final measure of viscoelastic material efficacy is expressed in terms of failure probabilities vs. survival time000.

Changes in stand structure and tree vigor with repeated prescribed fire in an Appalachian hardwood forest

Treesearch

Mary A. Arthur; Beth A. Blankenship; Angela Schörgendorfer; David L. Loftis; Heather D. Alexander

2015-01-01

Without large scale disturbances to alter forest structure and open the canopy, historically oak-dominated forests of the central and Appalachian hardwood regions of eastern North America are shifting to dominance by shade-tolerant, ‘mesophytic’ species. In response, prescribed fire is applied with increasing frequency and spatial extent to decrease non-oak species and...

Prescribed fire effects on structure in uneven-aged stands of loblolly and shortleaf pines

Treesearch

Michael D. Cain; T. Bently Wigley; Derik J. Reed

1998-01-01

Structure was assessed in uneven-aged stands of loblolly (Pinus taeda) and shortleaf pine (P. echinata) that were subjected to prescribed winter burns on cycles of 0, 3, 6, and 9 years. Vegetation assessments were made in late summer of 1990, 10 years after a single hardwood control treatment (basal injection of non-pine woody plants >2.5 cm in groundline diameter...

Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis

PubMed Central

Rice, Nigel; Dixon, Paul; Lloyd, David C E F; Roberts, David

2000-01-01

Objective To develop a weighted capitation formula for setting target allocations for prescribing expenditures for health authorities and primary care groups in England. Design Regression analysis relating prescribing costs to the demographic, morbidity, and mortality composition of practice lists. Setting 8500 general practices in England. Subjects Data from the 1991 census were attributed to practice lists on the basis of the place of residence of the practice population. Main outcome measures Variation in age, sex, and temporary resident originated prescribing units (ASTRO(97)-PUs) adjusted net ingredient cost of general practices in England for 1997-8 modelled for the impact of health and social needs after controlling for differences in supply. Results A needs gradient based on the four variables: permanent sickness, percentage of dependants in no carer households, percentage of students, and percentage of births on practice lists. These, together with supply characteristics, explained 41% of variation in prescribing costs per ASTRO(97)-PU adjusted capita across practices. The latter alone explained about 35% of variation in total costs per head across practices. Conclusions The model has good statistical specification and contains intuitively plausible needs drivers of prescribing expenditure. Together with adjustments made for differences in ASTRO(97)-PUs the model is capable of explaining 62% (35%+0.65% (41%)) of variation in prescribing expenditure at practice level. The results of the study have formed the basis for setting target budgets for 1999-2000 allocations for prescribing expenditure for health authorities and primary care groups. PMID:10650026

Assessing prescribing practices of clozapine before and after the implementation of an updated risk evaluation and mitigation strategy

PubMed Central

2018-01-01

Introduction: Clozapine is an atypical antipsychotic medication approved for treatment-resistant schizophrenia and suicidal behavior in schizophrenia or schizoaffective disorders. Despite its therapeutic efficacy, clozapine is associated with several adverse effects, including agranulocytosis. In late 2015, the Food and Drug Administration updated the risk evaluation and mitigation strategy (REMS) for clozapine with new requirements for monitoring, prescribing, and dispensing. The purpose of this study was to evaluate clozapine prescribing practices at a Kentucky state psychiatric hospital before and after the implementation of the updated REMS program. Methods: The primary outcome of this study was to evaluate clozapine prescribing practices by identifying the number of patients on clozapine therapy in the 6 months pre and post updated REMS implementation. Included in the study were patients at a Kentucky state psychiatric hospital on clozapine therapy for the 24 months before the updated REMS implementation and in the 6-month study period after the implementation. The secondary objective of this study examined psychiatrist comfort level of prescribing clozapine. Results: Since the implementation of the updated REMS program, there has been an increased percentage of patients that were prescribed clozapine at a Kentucky state psychiatric hospital. This increase was not statistically significant (P = .2610). Discussion: The prescribing practices of clozapine within this facility did not differ significantly comparing pre- and post-REMS change in terms of number of patients prescribed clozapine, patient's dose, and therapy duration. Data from this study contributes to the body of knowledge evaluating this new standard of practice under the updated REMS.

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities.

PubMed

Furuno, Jon P; Comer, Angela C; Johnson, J Kristie; Rosenberg, Joseph H; Moore, Susan L; MacKenzie, Thomas D; Hall, Kendall K; Hirshon, Jon Mark

2014-10-01

Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Contraceptive Provision to Adolescent Females Prescribed Teratogenic Medications.

PubMed

Stancil, Stephani L; Miller, Melissa; Briggs, Holley; Lynch, Daryl; Goggin, Kathy; Kearns, Gregory

2016-01-01

Rates of adult women receiving contraceptive provision when simultaneously prescribed a known teratogen are alarmingly low. The prevalence of this behavior among pediatric providers and their adolescent patients is unknown. The objective of this study was to describe pediatric provider behaviors for prescribing teratogens concurrently with counseling, referral, and/or prescribing of contraception (collectively called contraceptive provision) in the adolescent population. A retrospective review was conducted examining visits in 2008-2012 by adolescents aged 14 to 25 years in which a known teratogen (US Food and Drug Administration pregnancy risk category D or X) was prescribed. The electronic medical records were queried for demographic information, evidence of contraceptive provision, and menstrual and sexual histories. The data were analyzed using standard statistical methods. Within 4172 clinic visits, 1694 females received 4506 prescriptions for teratogenic medications. The most commonly prescribed teratogens were topiramate, methotrexate, diazepam, isotretinoin, and enalapril. The subspecialties prescribing teratogens most frequently were neurology, hematology-oncology, and dermatology. Overall, contraceptive provision was documented in 28.6% of the visits. Whites versus nonwhites and older versus younger girls were more likely to receive contraceptive provision. The presence of a federal risk mitigation system for the teratogen also increased the likelihood of contraceptive provision. Our data demonstrate female adolescents prescribed teratogens receive inadequate contraception provision, which could increase their risk for negative pregnancy outcomes. Although the presence of a federal risk mitigation system appears to improve contraceptive provision, these systems are costly and, in some instances, difficult to implement. Efforts to improve provider practices are needed. Copyright © 2016 by the American Academy of Pediatrics.

Comparison of prescribing indicators of academic versus non-academic specialist physicians in Urmia, Iran

PubMed Central

Sadigh-Rad, Laya; Majdi, Leila; Javaezi, Mehrnush; Delirrad, Mohammad

2015-01-01

Objective: As chief prescribers, physicians could have a key role in rational drug use. Core prescribing indicators of all physicians have been evaluated in the Islamic Republic of Iran for several years, but no study has assessed the effects of academic status of doctors on their prescribing behaviors. We aimed to compare prescribing indicators of two groups of academic and non-academic specialist physicians working in Urmia, Iran. Methods: In this cross-sectional study, prescribing indicators of the total number of 37 academic and 104 non-academic specialist physicians in six medical specialties (infectious diseases, psychiatry, otorhinolaryngology, gynecology, pediatrics and general surgery) were studied during 2012 using Rx-analyzer, a dedicated computer application. A set of five quality indicators was used based on the World Health Organization and International Network for Rational Use of Drugs recommendations. Findings: Totally, 709,771 medications in 269,660 prescriptions were studied. For academic and non-academic specialist physicians, the average number of medications per prescription was 2.26 and 2.65, respectively. Similarly, patients’ encounters with injectable pharmaceuticals were 17.37% and 26.76%, respectively. The corresponding figures for antimicrobial agents were 33.12% and 45.46%, respectively. The average costs of every prescription were 6.53 and 3.30 United States Dollar for academic and non-academic specialist physicians, respectively. All the above-mentioned differences were statistically significant. Conclusion: Better prescribing patterns were observed in academic specialist physicians. However, they prescribed medications that were more expensive, while the reason was not investigated in this study. Further studies may reveal the exact causes of these differences. PMID:25984540

Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates.

PubMed

Dowell, Deborah; Zhang, Kun; Noonan, Rita K; Hockenberry, Jason M

2016-10-01

To address the opioid overdose epidemic in the United States, states have implemented policies to reduce inappropriate opioid prescribing. These policies could affect the coincident heroin overdose epidemic by either driving the substitution of heroin for opioids or reducing simultaneous use of both substances. We used IMS Health's National Prescription Audit and government mortality data to examine the effect of these policies on opioid prescribing and on prescription opioid and heroin overdose death rates in the United States during 2006-13. The analysis revealed that combined implementation of mandated provider review of state-run prescription drug monitoring program data and pain clinic laws reduced opioid amounts prescribed by 8 percent and prescription opioid overdose death rates by 12 percent. We also observed relatively large but statistically insignificant reductions in heroin overdose death rates after implementation of these policies. This combination of policies was effective, but broader approaches to address these coincident epidemics are needed. Project HOPE—The People-to-People Health Foundation, Inc.

Factors influencing pharmacists’ adoption of prescribing: qualitative application of the diffusion of innovations theory

PubMed Central

2013-01-01

Background In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Methods Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Results Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges. Conclusions Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours. PMID:24034176

Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory.

PubMed

Makowsky, Mark J; Guirguis, Lisa M; Hughes, Christine A; Sadowski, Cheryl A; Yuksel, Nese

2013-09-14

In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists' adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists' adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists' decisions to apply for independent prescribing privileges. Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists' adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists' prescribing behaviours.

Implementing nurse prescribing: a case study in diabetes.

PubMed

Stenner, Karen; Carey, Nicola; Courtenay, Molly

2010-03-01

This paper is a report of a study exploring the views of nurses and team members on the implementation of nurse prescribing in diabetes services. Nurse prescribing is adopted as a means of improving service efficiency, particularly where demand outstretches resources. Although factors that support nurse prescribing have been identified, it is not known how these function within specific contexts. This is important as its uptake and use varies according to mode of prescribing and area of practice. A case study was undertaken in nine practice settings across England where nurses prescribed medicines for patients with diabetes. Thematic analysis was conducted on qualitative data from 31 semi-structured interviews undertaken between 2007 and 2008. Participants were qualified nurse prescribers, administrative staff, physicians and non-nurse prescribers. Nurses prescribed more often following the expansion of nurse independent prescribing rights in 2006. Initial implementation problems had been resolved and few current problems were reported. As nurses' roles were well-established, no major alterations to service provision were required to implement nurse prescribing. Access to formal and informal resources for support and training were available. Participants were accepting and supportive of this initiative to improve the efficiency of diabetes services. The main factors that promoted implementation of nurse prescribing in this setting were the ability to prescribe independently, acceptance of the prescribing role, good working relationships between doctors and nurses, and sound organizational and interpersonal support. The history of established nursing roles in diabetes care, and increasing service demand, meant that these diabetes services were primed to assimilate nurse prescribing.

Danish physicians' preferences for prescribing escitalopram over citalopram and sertraline to treatment-naïve patients: a national, register-based study.

PubMed

Poulsen, Karen Killerup; Glintborg, Dorte; Moreno, Søren Ilsøe; Thirstrup, Steffen; Aagaard, Lise; Andersen, Stig Ejdrup

2013-05-01

To investigate whether general practitioners, hospital physicians and specialized practitioners in psychiatry have similar preferences for initiating treatment with expensive serotonin-specific reuptake inhibitors (SSRIs). All first-time prescriptions for the SSRIs escitalopram, citalopram and sertraline reported to the Danish National Register of Medicinal Product Statistics from April 1, 2009 until March 31, 2010 were analysed with regard to treatment naivety and type of prescriber. A prescription was considered as first time if the patient had not received a prescription for the same drug within the last 2 years. Patients who had not received a prescription for an antidepressant within 6 months prior to the date of redemption were classified as treatment-naïve. We included 82,702 first-time prescriptions, 65,313 (79 %) of which were for treatment-naïve patients. Of the treatment-naïve patients, 19 % were initially prescribed escitalopram. Hospital physicians prescribed escitalopram to 34 % of their treatment-naïve patients, while practitioners specialized in psychiatry prescribed it to 25 %, and general practitioners prescribed it to 17 %. General practitioners, however, were responsible for initiating 87 % of all treatment-naïve patients. The most expensive SSRI, escitalopram, is prescribed as first choice to one in five patients receiving their first antidepressant of escitalopram, citalopram or sertraline. General practitioners made the bulk of all first-time SSRI prescriptions to treatment-naïve patients.

A 20-Year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia.

PubMed

Harrow, Martin; Jobe, Thomas H; Faull, Robert N; Yang, Jie

2017-10-01

To assess the long-term effectiveness of antipsychotic medications in facilitating work functioning in patients with schizophrenia we conducted longitudinal multifollowup research on 139 initially psychotic patients. The 70 patients with schizophrenia and 69 initially psychotic mood disordered control patients were followed up 6 times over 20 years. We compared the influence on work functioning of patients with schizophrenia continuously prescribed antipsychotics with patients with schizophrenia not prescribed antipsychotics, using statistical controls for inter-subject differences. While antipsychotics reduce or eliminate flagrant psychosis for most patients with schizophrenia at acute hospitalizations, four years later and continually until the 20 year followups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning. The work performance of the patients who were continuously prescribed antipsychotics was at a low rate and did not improve over time. Multiple other factors also interfere with work functioning. The data suggest that some patients with schizophrenia not prescribed antipsychotics for prolonged periods can function relatively well. Multiple other factors are associated with poor post-hospital work performance. The longitudinal data raise questions about prolonged treatment of schizophrenia with antipsychotic medications. Copyright © 2017 Elsevier B.V. All rights reserved.

Remotely controlled biking is associated with improved adherence to prescribed cycling speed.

PubMed

Jeong, In Cheol; Finkelstein, Joseph

2015-01-01

Individuals with mobility impairment may benefit from passive exercise mode which can be subsequently enhanced by an active exercise program. However, it is unclear which exercise mode promotes higher adherence to prescribed exercise intensity. The goal of this project was to compare adherence to prescribed speed during passive and active cycling exercise. We used cross-over study design in which subjects followed the same cycling intensity prescription for passive and active exercise modes in a random sequence. Coefficient of variation (CV) and speed differences were used to estimate extent of deviation from the prescribed trajectory. CV varied from 5.2% to 20.4% for the active mode and from 2.8% to 4.5% for the passive mode respectively. Though the CV differences did not reach statistical significance, analysis of cycling speed adherence of 120-second periods showed significantly higher cycling adherence during passive mode for each target cycling speed. Our results indicated that the passive mode may promote exercise safety and efficacy by helping patients who have safety concerns such as the frail elderly, patients with cardiovascular conditions or people with other contraindications for excessive exertion during exercise, in following the optimal intensity trajectory prescribed by their provider.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.

PubMed

Page, N; Baysari, M T; Westbrook, J I

2017-09-01

To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems. PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness. Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits. The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system. Copyright © 2017 Elsevier B.V. All rights reserved.

Evaluation of fire weather forecasts using PM2.5 sensitivity analysis

NASA Astrophysics Data System (ADS)

Balachandran, Sivaraman; Baumann, Karsten; Pachon, Jorge E.; Mulholland, James A.; Russell, Armistead G.

2017-01-01

Fire weather forecasts are used by land and wildlife managers to determine when meteorological and fuel conditions are suitable to conduct prescribed burning. In this work, we investigate the sensitivity of ambient PM2.5 to various fire and meteorological variables in a spatial setting that is typical for the southeastern US, where prescribed fires are the single largest source of fine particulate matter. We use the method of principle components regression to estimate sensitivity of PM2.5, measured at a monitoring site in Jacksonville, NC (JVL), to fire data and observed and forecast meteorological variables. Fire data were gathered from prescribed fire activity used for ecological management at Marine Corps Base Camp Lejeune, extending 10-50 km south from the PM2.5 monitor. Principal components analysis (PCA) was run on 10 data sets that included acres of prescribed burning activity (PB) along with meteorological forecast data alone or in combination with observations. For each data set, observed PM2.5 (unitless) was regressed against PCA scores from the first seven principal components (explaining at least 80% of total variance). PM2.5 showed significant sensitivity to PB: 3.6 ± 2.2 μg m-3 per 1000 acres burned at the investigated distance scale of ∼10-50 km. Applying this sensitivity to the available activity data revealed a prescribed burning source contribution to measured PM2.5 of up to 25% on a given day. PM2.5 showed a positive sensitivity to relative humidity and temperature, and was also sensitive to wind direction, indicating the capture of more regional aerosol processing and transport effects. As expected, PM2.5 had a negative sensitivity to dispersive variables but only showed a statistically significant negative sensitivity to ventilation rate, highlighting the importance of this parameter to fire managers. A positive sensitivity to forecast precipitation was found, consistent with the practice of conducting prescribed burning on days when rain can naturally extinguish fires. Perhaps most importantly for land managers, our analysis suggests that instead of relying on the forecasts from a day before, prescribed burning decisions should be based on the forecasts released the morning of the burn when possible, since these data were more stable and yielded more statistically robust results.

Effects of repeated growing season prescribed fire on the structure and composition of pine-hardwood forests in the southeastern Piedmont, USA

Treesearch

Matthew Reilly; Kenneth Outcalt; Joseph O’Brien; Dale Wade

2016-01-01

We examined the effects of repeated growing season prescribed fire on the structure and composition of mixed pine–hardwood forests in the southeastern Piedmont region, Georgia, USA. Plots were burned two to four times over an eight-year period with low intensity surface fires during one of four six-week long periods from early April to mid-September. Density...

On the interaction of solutes with grain boundaries

DOE PAGES

Dingreville, Remi Philippe Michel; Berbenni, Stephane

2015-11-01

Solute segregation to grain boundaries is considered by modeling solute atoms as misfitting inclusions within a disclination structural unit model describing the grain boundary structure and its intrinsic stress field. The solute distribution around grain boundaries is described through Fermi–Dirac statistics of site occupancy. The susceptibility of hydrogen segregation to symmetric tilt grain boundaries is discussed in terms of the misorientation angle, the defect type characteristics at the grain boundary, temperature, and the prescribed bulk hydrogen fraction of occupied sites. Through this formalism, it is found that hydrogen trapping on grain boundaries clearly correlates with the grain boundary structure (i.e.more » type of structural unit composing the grain boundary), and the associated grain boundary misorientation. Specifically, for symmetric tilt grain boundaries about the [001] axis, grain boundaries composed of both B and C structural units show a lower segregation susceptibility than other grain boundaries. A direct correlation between the segregation susceptibility and the intrinsic net defect density is provided through the Frank–Bilby formalism. Moreover, the present formulation could prove to be a simple and useful model to identify classes of grain boundaries relevant to grain boundary engineering.« less

On the interaction of solutes with grain boundaries

DOE Office of Scientific and Technical Information (OSTI.GOV)

Dingreville, Remi Philippe Michel; Berbenni, Stephane

Solute segregation to grain boundaries is considered by modeling solute atoms as misfitting inclusions within a disclination structural unit model describing the grain boundary structure and its intrinsic stress field. The solute distribution around grain boundaries is described through Fermi–Dirac statistics of site occupancy. The susceptibility of hydrogen segregation to symmetric tilt grain boundaries is discussed in terms of the misorientation angle, the defect type characteristics at the grain boundary, temperature, and the prescribed bulk hydrogen fraction of occupied sites. Through this formalism, it is found that hydrogen trapping on grain boundaries clearly correlates with the grain boundary structure (i.e.more » type of structural unit composing the grain boundary), and the associated grain boundary misorientation. Specifically, for symmetric tilt grain boundaries about the [001] axis, grain boundaries composed of both B and C structural units show a lower segregation susceptibility than other grain boundaries. A direct correlation between the segregation susceptibility and the intrinsic net defect density is provided through the Frank–Bilby formalism. Moreover, the present formulation could prove to be a simple and useful model to identify classes of grain boundaries relevant to grain boundary engineering.« less

Interventions to Improve Suboptimal Prescribing in Nursing Homes: A Narrative Review

PubMed Central

Marcum, Zachary A.; Handler, Steven M.; Wright, Rollin; Hanlon, Joseph T.

2010-01-01

Background Appropriate medication prescribing for nursing home residents remains a challenge. Objective The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. Methods The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors’ files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. Results Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention’s impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in ≥1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. Conclusions Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature. PMID:20624609

Do clinical practice education groups result in sustained change in GP prescribing?

PubMed

Richards, Dee; Toop, Les; Graham, Patrick

2003-04-01

Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.

Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses.

PubMed

Ringwalt, Chris; Gugelmann, Hallam; Garrettson, Mariana; Dasgupta, Nabarun; Chung, Arlene E; Proescholdbell, Scott K; Skinner, Asheley Cockrell

2014-01-01

Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians' opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. To examine the relationships between physicians' and other providers' primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ2<⁄span> statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients' pain diagnoses and demographic characteristics. Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner⁄family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races⁄ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.

Determinants of prescribed drug use among pregnant women in Bahir Dar city administration, Northwest Ethiopia: a cross sectional study.

PubMed

Admasie, Chanie; Wasie, Belaynew; Abeje, Gedefaw

2014-09-18

Drug use during pregnancy may be dangerous to the fetus. There is high consumption of prescribed drugs among pregnant women. This condition may be much higher in developing countries. There is no sufficient evidence on prescribed drug use among pregnant women in Bahir Dar town. The aim of this study was to assess the level of prescribed drug use and associated factors among pregnant women attending antenatal care (ANC) service at government health centers in Bahir Dar city administration. Institution based cross sectional study was used. Data were collected from randomly selected 510 pregnant women. Data were analyzed using SPSS version 16.0. Back ward stepwise logistic regression model was used and p-values <0.05 were considered statistically significant. A total of 510 pregnant women were included in the study of which 88.4% were prescribed at least one drug during pregnancy. Nearly 11% of the pregnant women were prescribed with drugs from category D or X of the US-FDA risk classification.Prescribed drug use among pregnant women was more likely when the pregnancy is wanted, (AOR = 2.4, 95% CI: 1.3 - 4.6), if the mother had maternal illness (AOR = 8.5, 95% CI: 5.4-13.4), when the educational level of ANC provider is diploma (AOR = 2.7, 95% CI: 1.5-4.7) and when number of pregnancies is more (AOR =2.1, 95% CI: 1.3-3.3). Prescribed drug use including those with potential harm to the fetus during pregnancy was very high in Bahir Dar city administration. Prescribed drug use is more when the woman had illness, when the woman was multi gravida and when the educational level of ANC provider was low (diploma). It is important to upgrade providers' educational level and institute prevention of diseases like malaria to reduce the level of prescribed drug use during pregnancy.

Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses

PubMed Central

Ringwalt, Chris; Gugelmann, Hallam; Garrettson, Mariana; Dasgupta, Nabarun; Chung, Arlene E; Proescholdbell, Scott K; Skinner, Asheley Cockrell

2014-01-01

BACKGROUND: Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians’ opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. OBJECTIVE: To examine the relationships between physicians’ and other providers’ primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). METHODS: Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ2 statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients’ pain diagnoses and demographic characteristics. RESULTS: Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner/family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races/ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). CONCLUSIONS: Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP. PMID:24809067

Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis

PubMed Central

Chang, Hsien-Yen; Lyapustina, Tatyana; Rutkow, Lainie; Daubresse, Matthew; Richey, Matt; Faul, Mark; Stuart, Elizabeth A.; Alexander, G. Caleb

2016-01-01

Background Prescription drug monitoring programs (PDMPs) and pill mill laws were implemented to reduce opioid-related injuries/deaths. We evaluated their effects on high-risk prescribers in Florida. Methods We used IMS Health's LRx Lifelink database between July 2010 and September 2012 to identify opioid-prescribing prescribers in Florida (intervention state, N: 38,465) and Georgia (control state, N: 18,566). The pre-intervention, intervention, and post-intervention periods were: July 2010–June 2011, July 2011–September 2011, and October 2011–September 2012. High-risk prescribers were those in the top 5th percentile of opioid volume during four consecutive calendar quarters. We applied comparative interrupted time series models to evaluate policy effects on clinical practices and monthly prescribing measures for low-risk/high-risk prescribers. Results We identified 1526 (4.0%) high-risk prescribers in Florida, accounting for 67% of total opioid volume and 40% of total opioid prescriptions. Relative to their lower-risk counterparts, they wrote sixteen times more monthly opioid prescriptions (79 vs. 5, p < 0.01), and had more prescription-filling patients receiving opioids (47% vs. 19%, p < 0.01). Following policy implementation, Florida's high-risk providers experienced large relative reductions in opioid patients and opioid prescriptions (−536 patients/month, 95% confidence intervals [CI] −829 to −243; −847 prescriptions/month, CI −1498 to −197), morphine equivalent dose (−0.88 mg/month, CI −1.13 to −0.62), and total opioid volume (−3.88 kg/month, CI −5.14 to −2.62). Low-risk providers did not experience statistically significantly relative reductions, nor did policy implementation affect the status of being high- vs. low- risk prescribers. Conclusions High-risk prescribers are disproportionately responsive to state policies. However, opioidsprescribing remains highly concentrated among high-risk providers. PMID:27264166

Factors Influencing Successful Prescribing by Intern Doctors: A Qualitative Systematic Review

PubMed Central

R. Hansen, Christina; Bradley, Colin P.; Sahm, Laura J.

2016-01-01

As the majority of prescribing in hospital is undertaken by intern doctors, the aims of this systematic review were to compile the evidence of the qualitative literature on the views and experiences of intern doctors and to examine the role of the pharmacist in assisting in prescribing by interns. A systematic review of the qualitative literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The findings were synthesized using thematic analysis. Seven publications were included. Factors influencing prescribing behaviour were related to the environment; collaboration in medical teams; hierarchical structures; and patient and individual factors. This review confirmed that interns’ prescribing behaviour is influenced by multiple factors, and further highlighted the need for an educational intervention that supports the intern completing the prescribing task in a complex environment, and not just addresses the presumed knowledge gap(s). PMID:28970397

Factors Influencing Successful Prescribing by Intern Doctors: A Qualitative Systematic Review.

PubMed

R Hansen, Christina; Bradley, Colin P; Sahm, Laura J

2016-08-24

As the majority of prescribing in hospital is undertaken by intern doctors, the aims of this systematic review were to compile the evidence of the qualitative literature on the views and experiences of intern doctors and to examine the role of the pharmacist in assisting in prescribing by interns. A systematic review of the qualitative literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The findings were synthesized using thematic analysis. Seven publications were included. Factors influencing prescribing behaviour were related to the environment; collaboration in medical teams; hierarchical structures; and patient and individual factors. This review confirmed that interns' prescribing behaviour is influenced by multiple factors, and further highlighted the need for an educational intervention that supports the intern completing the prescribing task in a complex environment, and not just addresses the presumed knowledge gap(s).

Venous thromboembolism prophylaxis risk assessment in a general surgery cohort: a closed-loop audit.

PubMed

McGoldrick, D M; Redmond, H P

2017-08-01

Venous thromboembolism (VTE) is a potential source of morbidity and mortality in surgical in-patients. A number of guidelines exist that advise on prophylactic measures. We aimed to assess VTE prophylaxis prescribing practices and compliance with a kardex-based risk assessment tool in a general surgery population. Data on general surgery in-patients were collected on two separate wards on two separate days. Drug kardexes were assessed for VTE prophylaxis measures and use of the risk assessment tool. NICE and SIGN guidelines were adopted as a gold standard. The audit results and information on the risk assessment tool were presented as an educational intervention at two separate departmental teaching sessions. A re-audit was completed after 3 months. In Audit A, 74 patients were assessed. 70% were emergency admissions. The risk assessment tool was completed in 2.7%. 75 and 97% of patients were correctly prescribed anti-embolic stockings (AES) and low-molecular weight heparin (LMWH), respectively. 30 patients were included in Audit B, 56% of whom were emergency admissions. 66% had a risk assessment performed, a statistically significant improvement (p < 0.0001). Rates of LMWH prescribing were similar (96%), but AES prescribing was lower (36%). Rates of LMWH prescribing are high in this general surgical population, although AES prescribing rates vary. Use of the VTE risk assessment tool increased following the initial audit and intervention.

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

PubMed Central

Shah, Priya; Wyatt, Jeremy C; Makubate, Boikanyo; Cross, Frank W

2011-01-01

Objective Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems. Design A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task. Measurements The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems. Results Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04). Conclusions Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. PMID:21836158

Improving specialist drug prescribing in primary care using task and error analysis: an observational study.

PubMed

Chana, Narinder; Porat, Talya; Whittlesea, Cate; Delaney, Brendan

2017-03-01

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. Semi-structured interviews with key informants followed by an observational study involving GPs in the UK. Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed. The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence. A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety. © British Journal of General Practice 2017.

Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel.

PubMed

Sargent, Lucy; McCullough, Amanda; Del Mar, Chris; Lowe, John

2017-02-13

Delayed antibiotic prescribing reduces antibiotic use for acute respiratory infections in trials in general practice, but the uptake in clinical practice is low. The aim of the study was to identify facilitators and barriers to general practitioners' (GPs') use of delayed prescribing and to gain pharmacists' and the public's views about delayed prescribing in Australia. This study used the Theoretical Domains Framework and the Behaviour Change Wheel to explore facilitators and barriers to delayed prescribing in Australia. Forty-three semi-structured, face-to-face interviews with general practitioners, pharmacists and patients were conducted. Responses were coded into domains of the Theoretical Domains Framework, and specific criteria from the Behaviour Change Wheel were used to identify which domains were relevant to increasing the use of delayed prescribing by GPs. The interviews revealed nine key domains that influence GPs' use of delayed prescribing: knowledge; cognitive and interpersonal skills; memory, attention and decision-making processes; optimism; beliefs about consequences; intentions; goals; emotion; and social influences: GPs knew about delayed prescribing; however, they did not use it consistently, preferring to bring patients back for review and only using it with patients in a highly selective way. Pharmacists would support GPs and the public in delayed prescribing but would fill the prescription if people insisted. The public said they would delay taking their antibiotics if asked by their GP and given the right information on managing symptoms and when to take antibiotics. Using a theory-driven approach, we identified nine key domains that influence GPs' willingness to provide a delayed prescription to patients with an acute respiratory infection presenting to general practice. These data can be used to develop a structured intervention to change this behaviour and thus reduce antibiotic use for acute respiratory infections in general practice.

'Potentially inappropriate or specifically appropriate?' Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people.

PubMed

Clyne, Barbara; Cooper, Janine A; Hughes, Carmel M; Fahey, Tom; Smith, Susan M

2016-08-11

Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Current controlled trials ISRCTN41694007.

Prescribing by pharmacists in Alberta and its relation to culture and personality traits.

PubMed

Rosenthal, Meagen M; Houle, Sherilyn K D; Eberhart, Greg; Tsuyuki, Ross T

2015-01-01

As evidence for the efficacy of pharmacists' interventions, governments worldwide are developing legislation to formalize new practice approaches, including independent prescribing by pharmacists. Pharmacists in Alberta became the first in Canada availed of this opportunity; however, uptake of such has been slow. One approach to understanding this problem is through an examination of pharmacists who have already gained this ability. The primary objective of this study was to gain descriptive insight into the culture and personality traits of innovator, and early adopter, Alberta pharmacists with Additional Prescribing Authorization using the Organizational Culture Profile and Big Five Inventory. The study was a cross-sectional online survey of Alberta pharmacists who obtained Additional Prescribing Authorization (independent prescribing authority), in the fall of 2012. The survey contained three sections; the first contained basic demographic, background and practice questions; the second section contained the Organizational Culture Profile; and the third section contained the Big Five Inventory. Sixty-five survey instruments were returned, for a response rate of 39%. Respondents' mean age was 40 (SD 10) years. The top reason cited by respondents for applying for prescribing authority was to improve patient care. The majority of respondents perceived greater value in the cultural factors of competitiveness, social responsibility, supportiveness, performance orientation and stability, and may be more likely to exhibit behavior in line with the personality traits of extraversion, agreeableness, conscientiousness and openness. Inferential statistical analysis revealed a significant linear relationship between Organizational Culture Profile responses to cultural factors of social responsibility and competitiveness and the number of prescription adaptations provided. This insight into the experiences of innovators and early adopter pharmacist prescribers can be used to develop more specific and targeted knowledge implementation studies to improve the uptake and integration of prescribing by pharmacists. Copyright © 2015 Elsevier Inc. All rights reserved.

[Perceptions on electronic prescribing by primary care physicians in madrid healthcare service].

PubMed

Villímar Rodríguez, A I; Gangoso Fermoso, A B; Calvo Pita, C; Ariza Cardiel, G

To investigate the opinion of Primary Care physicians regarding electronic prescribing. Descriptive study by means of a questionnaire sent to 527 primary care physicians. June 2014. The questionnaire included closed questions about interest shown, satisfaction, benefits, weaknesses, and barriers, and one open question about difficulties, all of them referred to electronic prescribing. Satisfaction was measured using 1-10 scale, and benefits, weaknesses, and barriers were evaluated by a 5-ítems Likert scale. Interest was measured using both methods. The questionnaire was sent by e-mail for on line response through Google Drive® tool. A descriptive statistical analysis was performed. The response rate was 47% (248/527). Interest shown was 8.7 (95% CI; 8.5-8.9) and satisfaction was 7.9 (95% CI; 7.8-8). The great majority 87.9% (95% CI; 83.8-92%) of respondents used electronic prescribing where possible. Most reported benefits were: 73.4% (95% CI; 67.8-78.9%) of respondents considered that electronic prescribing facilitated medication review, and 59.3% (95% CI; 53.1-65.4) of them felt that it reduced bureaucratic burden. Among the observed weaknesses, they highlighted the following: 87.9% (95% CI; 83.8-92%) of respondents believed specialist care physicians should also be able to use electronic prescribing. Concerning to barriers: 30.2% (95% CI; 24.5-36%) of respondents think that entering a patient into the electronic prescribing system takes too much time, and 4% (95% CI; 1.6-6.5%) of them perceived the application as difficult to use. Physicians showed a notable interest in using electronic prescribing and high satisfaction with the application performance. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Does mental health staffing level affect antipsychotic prescribing? Analysis of Italian national statistics.

PubMed

Starace, Fabrizio; Mungai, Francesco; Barbui, Corrado

2018-01-01

In mental healthcare, one area of major concern identified by health information systems is variability in antipsychotic prescribing. While most studies have investigated patient- and prescriber-related factors as possible reasons for such variability, no studies have investigated facility-level characteristics. The present study ascertained whether staffing level is associated with antipsychotic prescribing in community mental healthcare. A cross-sectional analysis of data extracted from the Italian national mental health information system was carried out. For each Italian region, it collects data on the availability and use of mental health facilities. The rate of individuals exposed to antipsychotic drugs was tested for evidence of association with the rate of mental health staff availability by means of univariate and multivariate analyses. In Italy there were on average nearly 60 mental health professionals per 100,000 inhabitants, with wide regional variations (range 21 to 100). The average rate of individuals prescribed antipsychotic drugs was 2.33%, with wide regional variations (1.04% to 4.01%). Univariate analysis showed that the rate of individuals prescribed antipsychotic drugs was inversely associated with the rate of mental health professionals available in Italian regions (Kendall's tau -0.438, p = 0.006), with lower rates of antipsychotic prescriptions in regions with higher rates of mental health professionals. After adjustment for possible confounders, the total availability of mental health professionals was still inversely associated with the rate of individuals exposed to antipsychotic drugs. The evidence that staffing level was inversely associated with antipsychotic prescribing indicates that any actions aimed at decreasing variability in antipsychotic prescribing need to take into account aspects related to the organization of the mental health system.

An evaluation of knowledge, attitude, and practice of adverse drug reaction reporting among prescribers at a tertiary care hospital.

PubMed

Desai, Chetna K; Iyer, Geetha; Panchal, Jigar; Shah, Samidh; Dikshit, R K

2011-10-01

Spontaneous reporting is an important tool in pharmacovigilance. However, its success depends on cooperative and motivated prescribers. Under-reporting of adverse drug reactions (ADRs) by prescribers is a common problem. The present study was undertaken to evaluate the knowledge, attitude, and practices (KAP) regarding ADR reporting among prescribers at the Civil Hospital, Ahmedabad, to get an insight into the causes of under-reporting of ADRs. A pretested KAP questionnaire comprising of 15 questions (knowledge 6, attitude 5, and practice 4) was administered to 436 prescribers. The questionnaires were assessed for their completeness (maximum score 20) and the type of responses regarding ADR reporting. Microsoft Excel worksheet (Microsoft Office 2007) and Chi-Square test were used for statistical analysis. A total of 260 (61%) prescribers completed the questionnaire (mean score of completion 18.04). The response rate of resident doctors (70.7%) was better than consultants (34.5%) (P < 0.001). ADR reporting was considered important by 97.3% of the respondents; primarily for improving patient safety (28.8%) and identifying new ADRs (24.6%). A majority of the respondents opined that they would like to report serious ADRs (56%). However, only 15% of the prescribers had reported ADRs previously. The reasons cited for this were lack of information on where (70%) and how (68%) to report and the lack of access to reporting forms (49.2%). Preferred methods for reporting were e-mail (56%) and personal communication (42%). The prescribers are aware of the ADRs and the importance of their reporting. However, under reporting and lack of knowledge about the reporting system are clearly evident. Creating awareness about ADR reporting and devising means to make it easy and convenient may aid in improving spontaneous reporting.

A tool for prediction of risk of rehospitalisation and mortality in the hospitalised elderly: secondary analysis of clinical trial data

PubMed Central

Alassaad, Anna; Melhus, Håkan; Hammarlund-Udenaes, Margareta; Bertilsson, Maria; Gillespie, Ulrika; Sundström, Johan

2015-01-01

Objectives To construct and internally validate a risk score, the ‘80+ score’, for revisits to hospital and mortality for older patients, incorporating aspects of pharmacotherapy. Our secondary aim was to compare the discriminatory ability of the score with that of three validated tools for measuring inappropriate prescribing: Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert doctors to Right Treatment (START) and Medication Appropriateness Index (MAI). Setting Two acute internal medicine wards at Uppsala University hospital. Patient data were used from a randomised controlled trial investigating the effects of a comprehensive clinical pharmacist intervention. Participants Data from 368 patients, aged 80 years and older, admitted to one of the study wards. Primary outcome measure Time to rehospitalisation or death during the year after discharge from hospital. Candidate variables were selected among a large number of clinical and drug-specific variables. After a selection process, a score for risk estimation was constructed. The 80+ score was internally validated, and the discriminatory ability of the score and of STOPP, START and MAI was assessed using C-statistics. Results Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid or being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked to a lower risk of the outcome. These variables made up the components of the 80+ score. The C-statistics were 0.71 (80+), 0.57 (STOPP), 0.54 (START) and 0.63 (MAI). Conclusions We developed and internally validated a score for prediction of risk of rehospitalisation and mortality in hospitalised older people. The score discriminated risk better than available tools for inappropriate prescribing. Pending external validation, this score can aid in clinical identification of high-risk patients and targeting of interventions. PMID:25694461

Using aggregated, de-identified electronic health record data for multivariate pharmacosurveillance: a case study of azathioprine.

PubMed

Patel, Vishal N; Kaelber, David C

2014-12-01

To demonstrate the use of aggregated and de-identified electronic health record (EHR) data for multivariate post-marketing pharmacosurveillance in a case study of azathioprine (AZA). Using aggregated, standardized, normalized, and de-identified, population-level data from the Explore platform (Explorys, Inc.) we searched over 10 million individuals, of which 14,580 were prescribed AZA based on RxNorm drug orders. Based on logical observation identifiers names and codes (LOINC) and vital sign data, we examined the following side effects: anemia, cell lysis, fever, hepatotoxicity, hypertension, nephrotoxicity, neutropenia, and neutrophilia. Patients prescribed AZA were compared to patients prescribed one of 11 other anti-rheumatologic drugs to determine the relative risk of side effect pairs. Compared to AZA case report trends, hepatotoxicity (marked by elevated transaminases or elevated bilirubin) did not occur as an isolated event more frequently in patients prescribed AZA than other anti-rheumatic agents. While neutropenia occurred in 24% of patients (RR 1.15, 95% CI 1.07-1.23), neutrophilia was also frequent (45%) and increased in patients prescribed AZA (RR 1.28, 95% CI 1.22-1.34). After constructing a pairwise side effect network, neutropenia had no dependencies. A reduced risk of neutropenia was found in patients with co-existing elevations in total bilirubin or liver transaminases, supporting classic clinical knowledge that agranulocytosis is a largely unpredictable phenomenon. Rounding errors propagated in the statistically de-identified datasets for cohorts as small as 40 patients only contributed marginally to the calculated risk. Our work demonstrates that aggregated, standardized, normalized and de-identified population level EHR data can provide both sufficient insight and statistical power to detect potential patterns of medication side effect associations, serving as a multivariate and generalizable approach to post-marketing drug surveillance. Copyright © 2013 Elsevier Inc. All rights reserved.

Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework.

PubMed

Lee, Jay S; Parashar, Vartika; Miller, Jacquelyn B; Bremmer, Samantha M; Vu, Joceline V; Waljee, Jennifer F; Dossett, Lesly A

2018-07-01

Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior. Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing. Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines). Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.

Effects of past burning frequency on plant species structure and composition in dry dipterocarp forest

NASA Astrophysics Data System (ADS)

Wanthongchai, Dr.; Bauhus, Prof.; Goldammer, Prof.

2009-04-01

Anthropogenic burning in dry dipterocarp forests (DDF) has become a common phenomenon throughout Thailand. It is feared that too frequent fires may affect vegetation structure and composition and thus impact on ecosystem productivity. The aim of this study was to quantify the effects of prescribed fires on sites with different past burning regimes on vegetation structure and composition in the Huay Kha Khaeng Wildlife Sanctuary (HKK), Thailand. Fire frequency was determined from satellite images and ranged from frequent, infrequent, rare and unburned with fire occurrences of 7, 2, 1 and 0 out of the past 10 years, respectively. The pre-burn fuel loads, the overstorey and understorey vegetation structure and composition were determined to investigate the effects of the contrasting past burning regimes. The burning experiment was carried out, applying a three-strip head-fire burning technique. The vegetation structure and composition were sampled again one year after the fire to assess the fire impacts. Aboveground fine fuel loads increased with the length of fire-free interval. The woody plant structures of the frequently burned stand differed from those of the other less frequently burned stands. The species composition of the overstorey on the frequently burned site, in particular that of small sized trees (4.5-10 cm dbh), also differed significantly from that of the other sites. Whilst the ground vegetation including shrubs and herbs did not differ between the past burning regimes, frequent burning obviously promoted the proliferation of graminoid vegetation. There was no clear evidence showing that the prescribed fires affected the mortality of trees (dbh> 4.5 cm) on the sites of the different past burning regimes. The effects of prescribed burning on the understorey vegetation structures varied between the past burning regimes and the understorey vegetation type. Therefore, it is recommended that the DDF at HKK should be subjected to a prescribed fire frequency not shorter than every 6-7 years, or 1-2 fires per decade, to maintain ecosystem structure and function. Variation in time and space in this way, the biodiversity of the landscape may be maintained for the long-term. Keywords: Prescribed burning, burning history, burning frequency, plant species, vegetation structure, dry dipterocarp forest, Huay Kha Khaeng wildlife Sanctuary

Effectiveness of a cognitive behavioural workbook for changing beliefs about antipsychotic polypharmacy: analysis from a cluster randomized controlled trial.

PubMed

Thompson, Andrew; Sullivan, Sarah; Barley, Maddi; Moore, Laurence; Rogers, Paul; Sipos, Attila; Harrison, Glynn

2010-06-01

Educational workbooks have been used in psychiatry to influence patient but not clinician behaviour. Targeted education interventions to change prescribing practice in other areas of medicine have only looked at changes in prescribing and not attitudes or beliefs related to the prescribing. We aimed to examine whether clinicians' beliefs about a common prescribing issue in psychiatry (antipsychotic polypharmacy prescription) changed alongside behaviour as a result of a complex intervention. Medical and nursing staff were recruited from 19 general adult psychiatry units in the south-west of the UK as part of a cluster randomized controlled trial. A questionnaire was used to assess beliefs on the prescribing of antipsychotic polypharmacy as a secondary outcome before and after completion of a cognitive behavioural 'self-help' style workbook (one part of a complex intervention). A factor analysis suggested three dimensions of the questionnaire that corresponded to predetermined themes. The data were analysed using a random-effects regression model (adjusting for clustering) controlling for possible confounders. There was a significant change in beliefs on both of the factors: antipsychotic polypharmacy (coefficient = -0.89, P < 0.01) and rapid tranquilization (coefficient = -0.68, P = 0.01) specifically targeted by the workbook. There was a modest but statistically significant change in antipsychotic polypharmacy prescribing (odds ratio 0.43, 95% confidence intervals 0.21-0.90). The workbook appeared to change staff beliefs about antipsychotic polypharmacy, but achieving substantial changes in clinician behaviour may require further exploration of other factors important in complex prescribing issues.

Evaluation of a user guidance reminder to improve the quality of electronic prescription messages.

PubMed

Dhavle, A A; Corley, S T; Rupp, M T; Ruiz, J; Smith, J; Gill, R; Sow, M

2014-01-01

Prescribers' inappropriate use of the free-text Notes field in new electronic prescriptions can create confusion and workflow disruptions at receiving pharmacies that often necessitates contact with prescribers for clarification. The inclusion of inappropriate patient direction (Sig) information in the Notes field is particularly problematic. We evaluated the effect of a targeted watermark, an embedded overlay, reminder statement in the Notes field of an EHR-based e-prescribing application on the incidence of inappropriate patient directions (Sig) in the Notes field. E-prescriptions issued by the same exact cohort of 97 prescribers were collected over three time periods: baseline, three months after implementation of the reminder, and 15 months post implementation. Three certified and experienced pharmacy technicians independently reviewed all e-prescriptions for inappropriate Sig-related information in the Notes field. A physician reviewer served as the final adjudicator for e-prescriptions where the three reviewers could not reach a consensus. ANOVA and post hoc Tukey HSD tests were performed on group comparisons where statistical significance was evaluated at p<0.05. The incidence of inappropriate Sig-related information in the Notes field decreased from a baseline of 2.8% to 1.8% three months post-implementation and remained stable after 15 months. In addition, prescribers' use of the Notes decreased by 22% after 3 months and had stabilized at 18.7% below baseline after 15 months. Insertion of a targeted watermark reminder statement in the Notes field of an e-prescribing application significantly reduced the incidence of inappropriate Sig-related information in Notes and decreased prescribers' use of this field.

33 CFR 67.01-20 - Prescribing lines of demarcation.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 33 Navigation and Navigable Waters 1 2011-07-01 2011-07-01 false Prescribing lines of demarcation. 67.01-20 Section 67.01-20 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY AIDS TO NAVIGATION AIDS TO NAVIGATION ON ARTIFICIAL ISLANDS AND FIXED STRUCTURES General...

33 CFR 67.01-20 - Prescribing lines of demarcation.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 33 Navigation and Navigable Waters 1 2010-07-01 2010-07-01 false Prescribing lines of demarcation. 67.01-20 Section 67.01-20 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY AIDS TO NAVIGATION AIDS TO NAVIGATION ON ARTIFICIAL ISLANDS AND FIXED STRUCTURES General...

Smoke incursions into urban areas: simulation of a Georgia prescribed burn

Treesearch

Y. Liu; S. Goodrick; G. Achtemeier

2009-01-01

This study investigates smoke incursion into urban areas by examining a prescribed burn in central Georgia,USA, on 28 February 2007. Simulations were conducted with a regional modeling framework to understand transport, dispersion,and structure of smoke plumes, the air quality effects, sensitivity to emissions,...

The role of pharmaceutical marketing and other factors in prescribing decisions: the Yemeni experience.

PubMed

Al-Areefi, Mahmoud Abdullah; Hassali, Mohamed Azmi; Mohamed Ibrahim, Mohamed Izham B

2013-01-01

Prescribing decisions are a complex phenomenon and influenced by many pharmacological and non-pharmacological factors. Little is known about the actual prescribing behaviors of physicians or the factors behind their prescribing decisions. The objective of this study was to explore the factors that influence physicians' prescribing decisions and the role of the marketing activities by pharmaceutical companies in this decision-making process. A semi-structured interview with the critical incident technique method was used to encourage physicians to describe the particular situations of prescribing for specific newly marketed drugs. All interviews were transcribed verbatim and thematic content analysis with systematic and comprehensive coding was employed to identify categories of physicians' reasons for either prescribing or not of the study drugs. Factors that influence prescribing of the study drugs (223 critical incidents) were categorized in six major themes. Drug characteristics, the most frequently mentioned by physicians as reasons of prescribe, were implicated in 70 (31.4%) incidents, followed by pharmaceutical company mentioned in 53 (23.8%) incidents, indications, 31 (13.9%) incidents, and patient contexts, 26 (11.7%) incidents. Environmental factors as information and evidence were implicated in 22 (9.9%) incidents, and physician factor, 21 (9.4%) incidents. Prescribing is a complex process and physicians integrate different factors. Although physicians make a considerable on patient contexts and treatment outcomes, they still rely on their personal experiences when making prescribing in addition to firms' source of information and firms' marketing activities. Copyright © 2013 Elsevier Inc. All rights reserved.

Computational design of RNAs with complex energy landscapes.

PubMed

Höner zu Siederdissen, Christian; Hammer, Stefan; Abfalter, Ingrid; Hofacker, Ivo L; Flamm, Christoph; Stadler, Peter F

2013-12-01

RNA has become an integral building material in synthetic biology. Dominated by their secondary structures, which can be computed efficiently, RNA molecules are amenable not only to in vitro and in vivo selection, but also to rational, computation-based design. While the inverse folding problem of constructing an RNA sequence with a prescribed ground-state structure has received considerable attention for nearly two decades, there have been few efforts to design RNAs that can switch between distinct prescribed conformations. We introduce a user-friendly tool for designing RNA sequences that fold into multiple target structures. The underlying algorithm makes use of a combination of graph coloring and heuristic local optimization to find sequences whose energy landscapes are dominated by the prescribed conformations. A flexible interface allows the specification of a wide range of design goals. We demonstrate that bi- and tri-stable "switches" can be designed easily with moderate computational effort for the vast majority of compatible combinations of desired target structures. RNAdesign is freely available under the GPL-v3 license. Copyright © 2013 Wiley Periodicals, Inc.

Opioid Prescribing Education in Surgical Residencies: A Program Director Survey.

PubMed

Yorkgitis, Brian K; Bryant, Elizabeth; Raygor, Desiree; Brat, Gabriel; Smink, Douglas S; Crandall, Marie

Opioid abuse and misuse is a public health crisis. A national effort to reduce this phenomenon is ongoing. Residents represent a large pool of opioid prescribers but, are often not the target for opioid prescribing education (OPE). We developed a survey to assess current opioid prescribing practices and education among surgical residents. An Institutional Review Board and Association of Program Directors in Surgery approved survey was electronically mailed to surgical program directors (PDs). The survey included questions regarding residency type, location, number of graduates per year, perceived value of OPE, residency policy on prescribing outpatients controlled substances, presence of OPE, and preferred method of OPE. A total of 248 PDs were e-mailed the survey with 110 complete responses (44.4%). Of all 104 (94.5%) allow residents to prescribe outpatient opioids with 24 (23.1%) limiting the opioid class prescribed. A total of 29 (27.9%) programs require residents to obtain their own Drug Enforcement Administration registration. Only 22 (20.0%) programs had in place mandatory OPE, 7 (6.4%) PDs were unsure if OPE was a mandatory educational requirement. Furthermore, 70 (79.5%) of programs currently without OPE are considering adding it. Didactic lecture (18, 81.8%) is the most common modality for OPE. The mode time dedicated to OPE was 1 hour. When PDs were asked about which method would be best to deliver OPE, the most common response was case-based scenarios (39, 35.5%). Bivariate statistics were performed and no association was found between OPE and program characteristics'. Most surgical residency programs allow residents to prescribe outpatient opioids, very few require OPE. The most common method of OPE was didactic lectures. To enhance a resident's knowledge in prescribing opioids, programs should incorporate OPE into their curriculum. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

PubMed Central

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-01-01

Introduction Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. Methods and analysis The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics and dissemination Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. PMID:26463224

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

PubMed

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-10-13

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Tree mortality patterns following prescribed fire for Pinus and Abies across the southwestern United States

USGS Publications Warehouse

van Mantgem, Philip J.; Nesmith, Jonathan C. B.; Keifer, MaryBeth; Brooks, Matthew

2012-01-01

The reintroduction of fire to historically fire-prone forests has been repeatedly shown to reduce understory fuels and promote resistance to high severity fire. However, there is concern that prescribed fire may also have unintended consequences, such as high rates of mortality for large trees and fire-tolerant Pinus species. To test this possibility we evaluated mortality patterns for two common genera in the western US, Pinus and Abies, using observations from a national-scale prescribed fire effects monitoring program. Our results show that mortality rates of trees >50 DBH were similar for Pinus (4.6% yr-1) and Abies (4.0% yr-1) 5 years following prescribed fires across seven sites in the southwestern US. In contrast, mortality rates of trees >50 cm DBH differed between Pinus (5.7% yr-1) and Abies (9.0% yr-1). Models of post-fire mortality probabilities suggested statistically significant differences between the genera (after including differences in bark thickness), but accounting for these differences resulted in only small improvements in model classification. Our results do not suggest unusually high post-fire mortality for large trees or for Pinus relative to the other common co-occurring genus, Abies, following prescribed fire in the southwestern US.

Stochastic Dual Algorithm for Voltage Regulation in Distribution Networks with Discrete Loads: Preprint

DOE Office of Scientific and Technical Information (OSTI.GOV)

Dall-Anese, Emiliano; Zhou, Xinyang; Liu, Zhiyuan

This paper considers distribution networks with distributed energy resources and discrete-rate loads, and designs an incentive-based algorithm that allows the network operator and the customers to pursue given operational and economic objectives, while concurrently ensuring that voltages are within prescribed limits. Four major challenges include: (1) the non-convexity from discrete decision variables, (2) the non-convexity due to a Stackelberg game structure, (3) unavailable private information from customers, and (4) different update frequency from two types of devices. In this paper, we first make convex relaxation for discrete variables, then reformulate the non-convex structure into a convex optimization problem together withmore » pricing/reward signal design, and propose a distributed stochastic dual algorithm for solving the reformulated problem while restoring feasible power rates for discrete devices. By doing so, we are able to statistically achieve the solution of the reformulated problem without exposure of any private information from customers. Stability of the proposed schemes is analytically established and numerically corroborated.« less

Stakeholders' views on granting prescribing authority to pharmacists in Nigeria: a qualitative study.

PubMed

Auta, Asa; Strickland-Hodge, Barry; Maz, Julia

2016-08-01

Background In Nigeria, only medical doctors, dentists and some nurses in primary care facilities have the legal right to prescribe medicines to patients. Patients' access to prescription medicines can be seriously affected by the shortage of prescribers leading to longer waiting times in hospitals. Objective This research was carried out to investigate stakeholders' views on granting prescribing authority to pharmacists in Nigeria. Setting The study was conducted in Nigeria. Methods Qualitative, semi-structured interviews were conducted with 43 Nigerian stakeholders including policymakers, pharmacists, doctors and patient group representatives. Transcribed interviews were entered into the QSR NVivo 10 software and analysed using a thematic approach. Main outcome measure Stakeholders' perception on the granting of prescribing authority to pharmacists in Nigeria. Results Three major themes emerged from the interviews: (1) prescribing as a logical role for pharmacists, (2) pharmacist prescribing- an opportunity or a threat and (3) the potential barriers to pharmacist prescribing. Many non-medical stakeholders including pharmacists and patient group representatives supported an extended role for pharmacists in prescribing while the majority of medical doctors including those in policy making were reluctant to do so. Generally, all stakeholders perceived that pharmacist prescribing represents an opportunity to increase patients' access to medicines, reduce doctors' workload and promote the utilisation of pharmacists' skills. However, many stakeholders including pharmacists and doctors commonly identified pharmacists' inadequate skills in diagnosis, medical resistance and shortage of pharmacists as potential barriers to the introduction of pharmacist prescribing in Nigeria. Conclusion The present study showed a split of opinion between participants who were medical doctors and those who were non-doctors in their support for pharmacist prescribing. However, all stakeholders acknowledged the potential of pharmacist prescribing to increase patients' access to medicines in Nigeria.

Investigation of prescribed movement in fluid–structure interaction simulation for the human phonation process☆

PubMed Central

Zörner, S.; Kaltenbacher, M.; Döllinger, M.

2013-01-01

In a partitioned approach for computational fluid–structure interaction (FSI) the coupling between fluid and structure causes substantial computational resources. Therefore, a convenient alternative is to reduce the problem to a pure flow simulation with preset movement and applying appropriate boundary conditions. This work investigates the impact of replacing the fully-coupled interface condition with a one-way coupling. To continue to capture structural movement and its effect onto the flow field, prescribed wall movements from separate simulations and/or measurements are used. As an appropriate test case, we apply the different coupling strategies to the human phonation process, which is a highly complex interaction of airflow through the larynx and structural vibration of the vocal folds (VF). We obtain vocal fold vibrations from a fully-coupled simulation and use them as input data for the simplified simulation, i.e. just solving the fluid flow. All computations are performed with our research code CFS++, which is based on the finite element (FE) method. The presented results show that a pure fluid simulation with prescribed structural movement can substitute the fully-coupled approach. However, caution must be used to ensure accurate boundary conditions on the interface, and we found that only a pressure driven flow correctly responds to the physical effects when using specified motion. PMID:24204083

Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study.

PubMed

Radomski, Thomas R; Bixler, Felicia R; Zickmund, Susan L; Roman, KatieLynn M; Thorpe, Carolyn T; Hale, Jennifer A; Sileanu, Florentina E; Hausmann, Leslie R M; Thorpe, Joshua M; Suda, Katie J; Stroupe, Kevin T; Gordon, Adam J; Good, Chester B; Fine, Michael J; Gellad, Walid F

2018-03-08

The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA. To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers. Qualitative study using semi-structured interviews. Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania). From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use. VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff. Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.

An object-based image analysis of pinyon and juniper woodlands treated to reduce fuels.

PubMed

Hulet, April; Roundy, Bruce A; Petersen, Steven L; Jensen, Ryan R; Bunting, Stephen C

2014-03-01

Mechanical and prescribed fire treatments are commonly used to reduce fuel loads and maintain or restore sagebrush steppe rangelands across the Great Basin where pinyon (Pinus) and juniper (Juniperus) trees are encroaching and infilling. Geospatial technologies, particularly remote sensing, could potentially be used in these ecosystems to (1) evaluate the longevity of fuel reduction treatments, (2) provide data for planning and designing future fuel-reduction treatments, and (3) assess the spatial distribution of horizontal fuel structure following fuel-reduction treatments. High-spatial resolution color-infrared imagery (0.06-m pixels) was acquired for pinyon and juniper woodland plots where fuels were reduced by either prescribed fire, tree cutting, or mastication at five sites in Oregon, California, Nevada, and Utah. Imagery was taken with a Vexcel UltraCam X digital camera in June 2009. Within each treatment plot, ground cover was measured as part of the Sagebrush Steppe Treatment Evaluation Project. Trimble eCognition Developer was used to classify land cover classes using object-based image analysis (OBIA) techniques. Differences between cover estimates using OBIA and ground-measurements were not consistently higher or lower for any land cover class and when evaluated for individual sites, were within ±5 % of each other. The overall accuracy and the K hat statistic for classified thematic maps for each treatment were: prescribed burn 85 % and 0.81; cut and fell 82 % and 0.77, and mastication 84 % and 0.80. Although cover assessments from OBIA differed somewhat from ground measurements, they are sufficiently accurate to evaluate treatment success and for supporting a broad range of management concerns.

Prescription drug use during pregnancy in Southern Tigray region, North Ethiopia.

PubMed

Molla, Fantahun; Assen, Admassu; Abrha, Solomon; Masresha, Birhanetensay; Gashaw, Arega; Wondimu, Abrham; Belete, Yared; Melkam, Wondim

2017-06-05

Judicious utilization of drugs rescues the fetus from the harmful effects while treating the health problems of the pregnant women. This study aimed at evaluating drug utilization pattern and its associated factors among pregnant women in Southern Tigray, Ethiopia. Institution based cross-sectional study was conducted among 647 pregnant women who had been attending obstetrics-gynecology and antenatal care units in different health facilities of Southern Tigray region. The study participants were selected using multistage sampling technique. Data collection was done using pre-tested semi-structured questionnaires and by reviewing antenatal follow-up cards. Descriptive and inferential statistics were analyzed, to assess drug utilization pattern and its associated factors among pregnant women, using SPSS version 20 software. Of 647 pregnant women, 87.5% were prescribed with at least one medication. As per the United States Food and Drug Administration (US-FDA) risk classification system, 87.7, 7.9, 3.9, and 0.5% of the prescribed drug were from category A, B, C and D, respectively. Prescription drug use was more likely among gynecology ward visitors [AOR = 8.97, 95% Cl (2.69-29.88)] and among those who visited health facilities for the first time during their first [AOR =2.65, 95% Cl (1.44-4.84)] and second [AOR = 2.50, 95% Cl (1.36-4.61)] trimesters. Majority of the study population used safe and appropriate medications according to US-FDA risk classification system, with the exception of low proportion (0.5%) of medication with potential risk for the fetus. The average number of drug prescribed per pregnant women was in the recommended range of WHO drug use indicators guideline.

Heterogeneity in the treatment of moderately severe scalp psoriasis in Scotland - results of a survey of Scottish health professionals.

PubMed

Smith, Douglas R W; Bottomley, Julia M; Auland, Merran; Jackson, Peter; Sharp, Judith

2011-01-01

Scalp psoriasis is a chronic recalcitrant condition. An aging literature for topical treatments used in clinical practice and no treatment guidelines means there is no current gold standard for its management in Scotland. There are no Scottish data on the resources and costs of treatment of the scalp psoriasis patient. Conduct a survey of Scottish healthcare professionals to understand how patients are typically managed to support the development of a model estimating the cost-effectiveness of a new treatment for moderately severe scalp psoriasis in Scotland. Experts from primary and secondary care were invited to participate in an interview programme to collect information on the management of scalp psoriasis in Scotland. This was further informed by Scottish prescribing statistics. Simple descriptive statistics were performed. Forty-three healthcare professionals (33 from primary care and ten in secondary care) completed the survey which illuminated national prescribing statistics. While an overall 72% response rate was achieved, representation from five of 14 Health Boards was not available. There was significant variation in stated patient pathways but some common themes. Most patients were treated initially with coal tar preparations and shampoos, then often progressing to topical potent corticosteroids. There was no consensus on the order patients might receive topicals thereafter although if referred for specialist review they would typically have been treated with three topicals in primary care first. Treatment in secondary care comprised application of topicals available in primary care or alternative preparations with nurse assistance to improve compliance. Phototherapy and systemic agents were not given to patients with scalp psoriasis alone. Study limitations are not considered to impact on the study observations. There was a large variety in first-, second- and third-line agents in primary care in scalp psoriasis although our interview programme and prescribing data confirmed which treatments were most frequently prescribed. Treatment heterogeneity reflects the limitations in current therapies, paucity of evidence-based effectiveness data and lack of clinical guidelines. Experts agreed 'current standard practice' in Scotland was best described as an average across five plausible treatment pathways.

Prescribed fire and timber harvest effects on terrestrial salamander abundance, detectability, and microhabitat use

Treesearch

Katherine M. O' Donnell; Frank R. Thompson; Raymond D. Semlitsch

2015-01-01

Prescribed fire and timber harvest are anthropogenic disturbances that modify resource availability and ecosystem structure, and can affect wildlife both directly and indirectly. Terrestrial salamanders are effective indicators of forest health due to their high abundance and sensitivity to microclimatic conditions. Given their ecological importance, it is critical to...

14 CFR 23.619 - Special factors.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false Special factors. 23.619 Section 23.619... Special factors. The factor of safety prescribed in § 23.303 must be multiplied by the highest pertinent special factors of safety prescribed in §§ 23.621 through 23.625 for each part of the structure whose...

Microsite and time since prescribed fire's influence on soil microbiology in a pinyon woodland

Treesearch

Benjamin M. Rau; Robert R. Blank; Tye Morgan

2008-01-01

Pinyon-juniper (Pinus monophylla Torr. & Frém.? Juniperus osteosperma Torr.) encroachment into sagebrush grasslands is a continuing problem in the Western United States. Prescribed burning has been suggested to slow woodland encroachment. We examined surface soil microbial community structure using Phospholipid Fatty Acid (PLFA...

Influence of regular reporting on local Pseudomonas aeruginosa and Acinetobacter spp. sensitivity to antibiotics on consumption of antibiotics and resistance patterns.

PubMed

Djordjevic, Z M; Folic, M M; Jankovic, S M

2017-10-01

Regular surveillance of antimicrobial resistance is an important component of multifaceted interventions directed at the problem with resistance of bacteria causing healthcare-associated infections (HAIs) in intensive care units (ICUs). Our aim was to analyse antimicrobial consumption and resistance among isolates of Pseudomonas aeruginosa and Acinetobacter spp. causing HAIs, before and after the introduction of mandatory reporting of resistance patterns to prescribers. A retrospective observational study was conducted between January 2011 and December 2015, at an interdisciplinary ICU of the Clinical Centre Kragujevac, Serbia. The intervention consisted of continuous resistance monitoring of all bacterial isolates from ICU patients and biannual reporting of results per isolate to prescribers across the hospital. Both utilization of antibiotics and density of resistant isolates of P. aeruginosa and Acinetobacter spp. were followed within the ICU. Resistance densities of P. aeruginosa to all tested antimicrobials were lower in 2015, in comparison with 2011. Although isolates of Acinetobacter spp. had lower resistance density in 2015 than in 2011 to the majority of investigated antibiotics, a statistically significant decrease was noted only for piperacillin/tazobactam. Statistically significant decreasing trends of consumption were recorded for third-generation cephalosporins, aminoglycosides and fluoroquinolones, whereas for the piperacillin/tazobactam, ampicillin/sulbactam and carbapenems, utilization trends were decreasing, but without statistical significance. In the same period, increasing trends of consumption were observed for tigecycline and colistin. Regular monitoring of resistance of bacterial isolates in ICUs and reporting of summary results to prescribers may lead to a significant decrease in utilization of some antibiotics and slow restoration of P. aeruginosa and Acinetobacter spp. susceptibility. © 2017 John Wiley & Sons Ltd.

Finite-element nonlinear transient response computer programs PLATE 1 and CIVM-PLATE 1 for the analysis of panels subjected to impulse or impact loads

NASA Technical Reports Server (NTRS)

Spilker, R. L.; Witmer, E. A.; French, S. E.; Rodal, J. J. A.

1980-01-01

Two computer programs are described for predicting the transient large deflection elastic viscoplastic responses of thin single layer, initially flat unstiffened or integrally stiffened, Kirchhoff-Lov ductile metal panels. The PLATE 1 program pertains to structural responses produced by prescribed externally applied transient loading or prescribed initial velocity distributions. The collision imparted velocity method PLATE 1 program concerns structural responses produced by impact of an idealized nondeformable fragment. Finite elements are used to represent the structure in both programs. Strain hardening and strain rate effects of initially isotropic material are considered.

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples. Volume 2: Software documentation

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes, These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples, volume 1

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

Nurses', physicians' and radiographers' perceptions of the safety of a nurse prescribing of ionising radiation initiative: A cross-sectional survey.

PubMed

Hyde, Abbey; Coughlan, Barbara; Naughton, Corina; Hegarty, Josephine; Savage, Eileen; Grehan, Jennifer; Kavanagh, Eoin; Moughty, Adrian; Drennan, Jonathan

2016-06-01

A new initiative was introduced in Ireland following legislative changes that allowed nurses with special training to prescribe ionising radiation (X-ray) for the first time. A small number of studies on nurse prescribing of ionising radiation in other contexts have found it to be broadly as safe as ionising radiation prescribing by physicians. Sociological literature on perceptions of safety indicates that these tend to be shaped by the ideological position of the professional rather than based on objective evidence. To describe, compare and analyse perceptions of the safety of a nurse prescribing of ionising radiation initiative across three occupational groups: nursing, radiography and medicine. A cross-sectional survey design. Participants were drawn from a range of clinical settings in Ireland. Respondents were 167 health professionals comprised of 49 nurses, 91 radiographers, and 27 physicians out of a total of 300 who were invited to participate. Non-probability sampling was employed and the survey was targeted specifically at health professionals with a specific interest in, or involvement with, the development of the nurse prescribing of ionising radiation initiative in Ireland. Comparisons of perspectives on the safety of nurse prescribing of ionising radiation across the three occupational groups captured by questionnaire were analysed using the Kruskal-Wallis H test. Pairwise post hoc tests were conducted using the Mann-Whitney U test. While the majority of respondents from all three groups perceived nurse prescribing of ionising radiation to be safe, the extent to which this view was held varied. A higher proportion of nurses was found to display confidence in the safety of nurse prescribing of ionising radiation compared to physicians and radiographers with differences between nurses' perceptions and those of the other two groups being statistically significant. That an occupational patterning emerged suggests that perceptions about safety and risk of nurse prescribing of ionising radiation are socially constructed according to the vantage point of the professional and may not reflect objective measures of safety. These findings need to be considered more broadly in the context of ideological barriers to expanding the role of nurses. Copyright © 2016 Elsevier Ltd. All rights reserved.

High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level

PubMed Central

2013-01-01

Background High risk prescribing can compromise independent wellbeing and quality of life in older adults. The aims of this project are to determine the prevalence, risk factors, clinical consequences, and costs of high risk prescribing, and to assess the impact of interventions on high risk prescribing in older people. Methods The proposed project will utilise data from the 45 and Up Study, a large scale cohort of 267,153 men and women aged 45 and over recruited during 2006–2009 from the state of New South Wales, Australia linked to a range of administrative health datasets. High risk prescribing will be assessed using three indicators: polypharmacy (use of five or more medicines); Beers Criteria (an explicit measure of potentially inappropriate medication use); and Drug Burden Index (a pharmacologic dose-dependent measure of cumulative exposure to anticholinergic and sedative medicines). Individual risk factors from the 45 and Up Study questionnaire, and health system characteristics from health datasets that are associated with the likelihood of high risk prescribing will be identified. The main outcome measures will include hospitalisation (first admission to hospital, total days in hospital, cause-specific hospitalisation); admission to institutionalised care; all-cause mortality, and, where possible, cause-specific mortality. Economic costs to the health care system and implications of high risk prescribing will be also investigated. In addition, changes in high risk prescribing will be evaluated in relation to certain routine medicines-related interventions. The statistical analysis will be conducted using standard pharmaco-epidemiological methods including descriptive analysis, univariate and multivariate regression analysis, controlling for relevant confounding factors, using a number of different approaches. Discussion The availability of large-scale data is useful to identify opportunities for improving prescribing, and health in older adults. The size of the 45 and Up Study, along with linkage to health databases provides an important opportunity to investigate the relationship between high risk prescribing and adverse outcomes in a real-world population of older adults. PMID:23388494

Generic medicines: Greek physicians' perceptions and prescribing practices.

PubMed

Tsiantou, V; Zavras, D; Kousoulakou, H; Geitona, M; Kyriopoulos, J

2009-10-01

The penetration of generic drugs in the Greek pharmaceutical market is placed among the weakest in the EU. The Greek regulatory framework does not systematically support the development of this subsector and physicians are not provided with incentives for prescribing generics. The aim of this study was to investigate the prescribing profile of physicians in Greece with a focus on the factors that influence their decision on generics prescribing. A structured questionnaire was sent by mail to a random national sample of 1463 physicians, stratified by sex, specialty and geographical region. The response rate was 82.3%. Greek physicians have a positive view on generics but they prefer to prescribe the original products. According to our analysis, physician's age and their opinion on generics' efficacy and effectiveness are identified as important determinants of their prescribing decision. The primary reason that could make them change their prescribing habits is the appearance of side-effects. Patients' insurance coverage and income, as well as the drug cost are also referred as factors that influence their prescribing decision. Despite the fact that they do not usually prescribe generics in their clinical practice, they are willing to substitute an original drug by a generic product. Our findings suggest that Greek physicians could be persuaded to prescribe generic medicines, if a generic promotion policy was introduced in the country. To develop such a policy, a set of supply side and demand-side measures should be implemented along with provision of information on generics to physicians during their education and clinical practice.

Continuing professional development needs of nursing and allied health professionals with responsibility for prescribing.

PubMed

Weglicki, Robert S; Reynolds, Julie; Rivers, Peter H

2015-01-01

Continuing professional development (CPD) for non-medical prescribers is recognised as being pivotal in maintaining up -to -date knowledge and skills influencing prescribing competence. This study was, therefore, designed to ascertain the aspirations, priorities and preferred mode of CPD for non-medical prescribers. Qualitative data were derived from semi-structured in-depth interviews and a focus group given by 16 allied health professionals working in primary and secondary care settings. A topic guide was used to cover clinical decision-making (including difficult decisions), legal aspects of prescribing and diagnostic issues. A content analysis of the verbatim transcripts enabled four key emerging themes to be identified, thus offering a basis for developing a greater understanding of the CPD needs of non-medical prescribers. The four key emerging themes identified are the following: Theme 1: "Personal anxiety undermining confidence to prescribe", Theme 2: "External barriers and other factors that exacerbate anxiety", Theme 3: "Need for support identified through coping strategies", and Theme 4: "Preferred mode or style of learning". The findings suggest that anxiety and lack of confidence in non-medical prescribing pose a significant challenge for CPD. Strategies that are most likely to improve prescribing confidence are through a blended learning approach. Local higher education and workplace employer collaboration is an appropriate step forward to achieve this. Copyright © 2014 Elsevier Ltd. All rights reserved.

Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study.

PubMed

van Buul, Laura W; van der Steen, Jenny T; Doncker, Sarah M M M; Achterberg, Wilco P; Schellevis, François G; Veenhuizen, Ruth B; Hertogh, Cees M P M

2014-12-16

Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors. Semi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff. The analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians' perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients' family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics). Our interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Physicians' Perception of Teratogenic Risk and Confidence in Prescribing Drugs in Pregnancy-Influence of Norwegian Drug Information Centers.

PubMed

Bakkebø, Tina; Widnes, Sofia Frost; Aamlid, Synnøve Stubmo; Schjøtt, Jan

2016-05-01

Clinical decision support provided by drug information centers is an intervention that can ensure rational drug therapy for pregnant women. We have examined whether physicians' teratogenic risk perceptions and confidence in prescribing drugs to pregnant women is altered after advice from the Norwegian drug information centers, Regional Medicines and Pharmacovigilance Centres i Norway (RELIS). Physicians who consulted RELIS for advice on patient-specific drug use in pregnancy from November 2013 to April 2014 completed questionnaires before and after receiving the advice. A scale from 1 to 7 was used to rate confidence in prescribing and perception of teratogenic risk. The lower part of the scale represented a low perception of teratogenic risk and a high confidence in prescribing a drug in pregnancy. The data were analyzed using a mixed linear model. A total of 45 physicians participated in the study and they assessed 64 drugs or categories of drugs. Advice from RELIS increased confidence in prescribing, with a statistically significant mean change on the scale from 4.1 to 2.9. The assessment of teratogenic risk was reduced after advice from RELIS, with a mean change from 3.2 to 2.5, though this was not significant. A subgroup of 26 physicians completed questionnaires both before and after advice from RELIS and assessed a total of 32 drugs or categories of drugs. In 94% of these assessments, advice from RELIS altered the physician's confidence in prescribing. Perception of teratogenic risk was altered in 78% of the assessments. Our results show that physicians' perception of teratogenic risk and confidence in prescribing drugs to pregnant women is influenced by advice from Norwegian drug information centers. Copyright © 2016 Elsevier HS Journals, Inc. All rights reserved.

Assembling Precise Truss Structures With Minimal Stresses

NASA Technical Reports Server (NTRS)

Sword, Lee F.

1996-01-01

Improved method of assembling precise truss structures involves use of simple devices. Tapered pins that fit in tapered holes indicate deviations from prescribed lengths. Method both helps to ensure precision of finished structures and minimizes residual stresses within structures.

14 CFR 25 - Traffic and Capacity Elements

Code of Federal Regulations, 2012 CFR

2012-01-01

... PROCEEDINGS) ECONOMIC REGULATIONS UNIFORM SYSTEM OF ACCOUNTS AND REPORTS FOR LARGE CERTIFICATED AIR CARRIERS... forth in section 19—Uniform Classification of Operating Statistics. (b) Carriers submitting Schedule T-100 shall use magnetic computer tape or IBM compatible disk for transmitting the prescribed data to...

14 CFR Section 25 - Traffic and Capacity Elements

Code of Federal Regulations, 2013 CFR

2013-01-01

... PROCEEDINGS) ECONOMIC REGULATIONS UNIFORM SYSTEM OF ACCOUNTS AND REPORTS FOR LARGE CERTIFICATED AIR CARRIERS... forth in section 19—Uniform Classification of Operating Statistics. (b) Carriers submitting Schedule T-100 shall use magnetic computer tape or IBM compatible disk for transmitting the prescribed data to...

Magnetic reconnection in collisionless plasmas - Prescribed fields

NASA Technical Reports Server (NTRS)

Burkhart, G. R.; Drake, J. F.; Chen, J.

1990-01-01

The structure of the dissipation region during magnetic reconnection in collisionless plasma is investigated by examining a prescribed two-dimensional magnetic x line configuration with an imposed inductive electric field E(y). The calculations represent an extension of recent MHD simulations of steady state reconnection (Biskamp, 1986; Lee and Fu, 1986) to the collisionless kinetic regime. It is shown that the structure of the x line reconnection configuration depends on only two parameters: a normalized inductive field and a parameter R which represents the opening angle of the magnetic x lines.

Contribution of Patient Interviews as Part of a Comprehensive Approach to the Identification of Drug-Related Problems on Geriatric Wards.

PubMed

Stämpfli, Dominik; Boeni, Fabienne; Gerber, Andy; Bättig, Victor A D; Hersberger, Kurt E; Lampert, Markus L

2018-06-19

Inappropriate prescribing is linked to increased risks for adverse drug reactions and hospitalisation. Combining explicit and implicit criteria of inappropriate prescribing with the information obtained in patient interviews seems beneficial with regard to the identification of drug-related problems (DRPs) in hospitalised patients. We aimed to investigate the inclusion of pharmacist interviews as part of medication reviews (including the use of explicit and implicit criteria of inappropriate prescribing) to identify DRPs in older inpatients. Clinical medication reviews were performed on geriatric and associated physical and neurological rehabilitation wards in a regional secondary care hospital. Data from electronic medical records, laboratory data, and current treatment regimens were complemented with a novel structured patient interview performed by a clinical pharmacist. The structured interview questioned patients on administration issues, prescribed medication, self-medication, and allergies. The reviews included the use of current treatment guidelines, the Medication Appropriateness Index, the Screening Tool of Older People's Prescriptions (STOPP, v2), and the Screening Tool to Alert to Right Treatment (START, v2). The potential relevance of the DRPs was estimated using the German version of the CLEO tool. In 110 patients, 595 DRPs were identified, averaging 5.4 per patient (range 0-17). The structured interviews identified 249 DRPs (41.8%), of which 227 were not identified by any other source of information. The majority of DRPs (213/249, i.e. 85.5%) identified by patient interview were estimated to be of minor clinical relevance (i.e. limited adherence, knowledge, quality of life, or satisfaction). We demonstrated that structured patient interviews identified additional DRPs that other sources did not identify. Embedded within a comprehensive approach, the structured patient interviews were needed as data resource for over one-third of all DRPs.

Properties of Forested Loess Soils After Repeated Prescribed Burns

Treesearch

D.M. Moehring; C.X. Grano; J.R. Bassett

1966-01-01

Nine annual burns have had little effect on the nutrient content and structure of the surface 4 inches of loess soils on flat terrain.Because prescribed burns must often be repeated to obtain desired results, many foresters are apprehensive about the possible deleterious effects on soils. In 1954 the Timber Management Laboratory at Crossett, Arkansas, in co-...

Effect of season and interval of prescribed burn on ponderosa pine butterfly defoliation patterns

Treesearch

Becky K. Kerns; Douglas J. Westlind

2013-01-01

Current knowledge concerning the interactions between forest disturbances such as fire and insect defoliation is limited. Wildfires and prescribed burns may influence the intensity and severity of insect outbreaks by affecting the vigor of residual trees, altering aspects of stand structure and abundance of preferred hosts, and by changing the physical environment...

Acorn viability following prescribed fire in upland hardwood forests

Treesearch

Katie Greenberg; Tara Keyser; Stan Zarnoch; Kris Connor

2012-01-01

Restoration of structure and function of mixed-oak (Quercus spp.) forests is a focal issue of forest land managers in the eastern United States due to widespread regeneration failure and poor overstory recruitment of oaks, particularly on productive sites. Prescribed fire is increasingly used as a tool in oak ecosystem restoration, with the goal of reducing competition...

Streptococcus pneumoniae non-susceptibility and outpatient antimicrobial prescribing rates at the Alaska Native Medical Center

PubMed Central

Stevens, Ryan W.; Wenger, Jay; Bulkow, Lisa; Bruce, Michael G.

2013-01-01

Background American Indian/Alaska Native (AI/AN) people suffer substantially higher rates of invasive pneumococcal disease (IPD) than the general US population. We evaluated antimicrobial prescribing data and their association with non-susceptibility in Streptococcus pneumoniae causing IPD in AI/AN people between 1992 and 2009. Methods Antimicrobial use data were gathered from the electronic patient management system and included all prescriptions dispensed to Alaska Native patients aged 5 years and older from outpatient pharmacies at the Alaska Native Medical Center (ANMC). Antimicrobial susceptibility data were gathered from pneumococcal isolates causing IPD among Anchorage Service Unit AI/AN residents aged 5 years and older. Data were restricted to serotypes not contained in the pneumococcal vaccine (PCV7). Results Over the study period, overall antimicrobial prescribing increased 59% (285/1,000 persons/year in 1992 to 454/1,000 persons per year in 2009, p<0.001). Trimethoprim/sulfamethoxazole prescribing increased (43/1,000 persons/year in 1992 to 108/1,000 persons/year in 2009, p<0.001) and non-susceptibility to trimethoprim/sulfamethoxazole in AI/AN patients ≥5 years of age increased in non-PCV7 serotypes (0–12%, p<0.05). Similarly, prescribing rates increased for macrolide antibiotics (46/1,000 persons/year in 1992 to 84/1,000 persons/year in 2009, p<0.05). We observed no statistically significant change over time in erythromycin non-susceptibility among non-PCV7 serotypes in AI/AN patients aged 5 years or greater (0–7%, p=0.087). Conclusion Antimicrobial prescribing patterns of some antibiotics in the AI/AN population corresponded to increased antimicrobial resistance in clinical isolates. This study highlights the on-going threat of antimicrobial resistance, the critical importance of judicious prescribing of antibiotics and the potential utility of prescribing data for addressing this issue. PMID:24358456

Approach of Turkish ophthalmologists to micronutrition in age-related macular degeneration.

PubMed

Muhammed, Şahin; Yüksel, Harun; Şahin, Alparslan; Cingü, Abdullah Kürşat; Türkcü, Fatih Mehmet; Özkurt, Zeynep Gürsel; Çaça, İhsan

2015-01-01

To evaluate the knowledge and behaviors of ophthalmologists in Turkey concerning micronutrition support in patients with age related macular degeneration (ARMD). This study involved 1,845 ophthalmologists. A scientific poll was sent to all participants by email. The survey covered the following: demographic features, subspecialty knowledge about micronutrition preference for prescribing micronutrition to age related macular degeneration patients, and the reason for this preference. If a participant indicated that he or she prescribed micronutrition, the participant was also asked to indicate the source of the treatment and supplemental treatments. Of 1,845 ophthalmologists, 249 responded to the survey. Of the respondents, 9% (22) never, 43% (107) sometimes, 37% (92) frequently, and 11% (27) always used micronutrition. The most frequent prescribing subgroup was general ophthalmology (22%), followed by the retina-uvea subspecialty (13.9%). The micronutrition prescribing ratio was 54.8% in retina-uvea specialists when the "frequent" and "always" responses were combined. There was no statistically significant difference between subgroups with respect to prescribing micronutrition. Among the ophthalmologists prescribing micronutrition, 57.1% of them did not use the Age-Related Eye Disease Study-1 (AREDS) criteria, and only 31.3% prescribe micronutrition according to AREDS criteria. The results for the general ophthalmologist and retina-uvea specialist subgroups were similar, 56.3% vs 20.2%, and 54.1% vs 36.1%, respectively. Micronutrition was not recommended for the following reasons: expensive (55.4%), low patient expectancy (40%), no effect (30%), and low patient drug compliance (25.4%). Moreover, 55.2% of the clinicians recommended physical activities, dietary changes, and smoking cessation; 7.3% did not recommend these behavioral changes. This survey demonstrated that micronutrition preference in age related macular degeneration was low in ophthalmologists in Turkey. Additionally, retina specialists have a lower rate of prescribing micronutrition. Micronutrition support and behavior such as smoking cessation, dietary changes, etc. should be recommended more often to patients with age related macular degeneration.

24 CFR 570.506 - Records to be maintained.

Code of Federal Regulations, 2012 CFR

2012-04-01

... attain or maintain any particular statistical measure by race, ethnicity, or gender in covered programs... CDBG funds, with such data maintained in the categories prescribed on the Equal Employment Opportunity... business and women's business enterprises have an equal opportunity to obtain or compete for contracts and...

24 CFR 570.506 - Records to be maintained.

Code of Federal Regulations, 2014 CFR

2014-04-01

... attain or maintain any particular statistical measure by race, ethnicity, or gender in covered programs... CDBG funds, with such data maintained in the categories prescribed on the Equal Employment Opportunity... business and women's business enterprises have an equal opportunity to obtain or compete for contracts and...

24 CFR 570.506 - Records to be maintained.

Code of Federal Regulations, 2013 CFR

2013-04-01

... attain or maintain any particular statistical measure by race, ethnicity, or gender in covered programs... CDBG funds, with such data maintained in the categories prescribed on the Equal Employment Opportunity... business and women's business enterprises have an equal opportunity to obtain or compete for contracts and...

The impact of the government health funding on prescribing behaviors in community health institutions in China.

PubMed

Sun, Gang; Lu, Zuxun; Gan, Yong; Dong, Xiaoxin; Li, Yongbin; Wang, Yunxia; Li, Liqing

2017-11-01

Government health funding (GHF) is a cosmopolitan problem. It is especially conspicuous in China, where drug sales become a main source of medical institutions' incomes due to limited GHF. This is well known as China's "drug maintain medical institutions (DMMIs)" system which results directly in very high use of antibiotics, injections, and corticosteroids. However, few statistical data existed in China on the association between the GHF and the prevalence of inappropriate drug prescribing, despite widespread acknowledgment of its existence.A multistage sampling strategy was employed to select 442,100 prescriptions written between 2007 and 2011 by urban community health (CH) institutions and check the GHF in 36 key cities (districts) across China. This study examined the association between the GHF and the prevalence of inappropriate drug prescribing, which differs somewhat from previous studies.The data suggested that from 2007 to 2011, with the increase of GHF, prescribing behaviors (PB) gradually improved on the whole although doctors still prescribed a few more drugs than the recommendations from World Health Organization (WHO). This study found that there is significant negative association between GHF and main indicators of PB (correlation coefficients more than 0.5).The findings implied that government should further perfect the compensation mechanism to medical institutions for gradually weakening the compensation function of drug sales in medical institutions.

The impact of the government health funding on prescribing behaviors in community health institutions in China

PubMed Central

Sun, Gang; Lu, Zuxun; Gan, Yong; Dong, Xiaoxin; Li, Yongbin; Wang, Yunxia; Li, Liqing

2017-01-01

Abstract Government health funding (GHF) is a cosmopolitan problem. It is especially conspicuous in China, where drug sales become a main source of medical institutions’ incomes due to limited GHF. This is well known as China's “drug maintain medical institutions (DMMIs)” system which results directly in very high use of antibiotics, injections, and corticosteroids. However, few statistical data existed in China on the association between the GHF and the prevalence of inappropriate drug prescribing, despite widespread acknowledgment of its existence. A multistage sampling strategy was employed to select 442,100 prescriptions written between 2007 and 2011 by urban community health (CH) institutions and check the GHF in 36 key cities (districts) across China. This study examined the association between the GHF and the prevalence of inappropriate drug prescribing, which differs somewhat from previous studies. The data suggested that from 2007 to 2011, with the increase of GHF, prescribing behaviors (PB) gradually improved on the whole although doctors still prescribed a few more drugs than the recommendations from World Health Organization (WHO). This study found that there is significant negative association between GHF and main indicators of PB (correlation coefficients more than 0.5). The findings implied that government should further perfect the compensation mechanism to medical institutions for gradually weakening the compensation function of drug sales in medical institutions. PMID:29145237

Frequent Prescribed Burning as a Long-term Practice in Longleaf Pine Forests Does Not Affect Detrital Chemical Composition.

PubMed

Coates, T Adam; Chow, Alex T; Hagan, Donald L; Wang, G Geoff; Bridges, William C; Dozier, James H

2017-09-01

The O horizon, or detrital layer, of forest soils is linked to long-term forest productivity and health. Fuel reduction techniques, such as prescribed fire, can alter the thickness and composition of this essential ecosystem component. Developing an understanding of the changes in the chemical composition of forest detritus due to prescribed fire is essential for forest managers and stakeholders seeking sustainable, resilient, and productive ecosystems. In this study, we evaluated fuel quantity, fuel structure, and detrital chemical composition in longleaf pine ( Miller) forests that have been frequently burned for the last 40 yr at the Tom Yawkey Wildlife Center in Georgetown, SC. Our results suggest that frequent prescribed fire reduces forest fuel quantity ( < 0.01) and vertical structure ( = 0.01). Using pyrolysis-gas chromatography/mass spectrometry as a molecular technique to analyze detrital chemical composition, including aromatic compounds and polycyclic aromatic hydrocarbons, we found that the chemical composition of forest detritus was nearly uniform for both unburned and burned detritus. Our burning activities varied in the short term, consisting of annual dormant, annual growing, and biennial dormant season burns. Seasonal distinctions were present for fuel quantity and vertical fuel structure, but these differences were not noted for the benzene/phenol ratio. These results are significant as more managers consider burning existing longleaf stands while determining effective management practices for longleaf stands yet to be established. Managers of such stands can be confident that frequent, low-intensity, low-severity prescribed burns in longleaf pine forests do little to affect the long-term chemical composition of forest detritus. Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

PubMed

Abuzour, Aseel S; Lewis, Penny J; Tully, Mary P

2018-03-01

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Use of Chinese herbal medicine among menopausal women in Taiwan.

PubMed

Chen, Lih-Chi; Wang, Bi-Ru; Chen, I-Chin; Shao, Chun-Hui

2010-04-01

To assess the patterns of use of Chinese herbal medicine (CHM) used by women in Taiwan to treat menopausal symptoms. A retrospective review of the records of women who received CHM therapies for menopausal symptoms at the Traditional Medicine Center, Veterans General Hospital, Taipei, between January 2003 and December 2006. The average number of therapies per prescription, dosage, and duration of the prescription were recorded. The most commonly prescribed herbs and formulae were also recorded. Data were analyzed using descriptive statistics. The records of 3432 women who were administered a total of 19370 CHMs to treat symptoms of the menopause were reviewed. The average number of drugs per prescription was 5.64. Most of the prescriptions (97.1%) were prescribed to be taken 3 times a day. The most commonly prescribed Chinese herb was Leonurus heterophyllus. Jia-Wey-Shiau-Yau-San was the most commonly prescribed Chinese herbal formula. CHM is commonly used in Taiwan for the treatment of menopausal symptoms. The efficacy and safety of CHM drugs used for the management of menopausal symptoms require further study. Copyright 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Predictive Modeling of Physician-Patient Dynamics That Influence Sleep Medication Prescriptions and Clinical Decision-Making

NASA Astrophysics Data System (ADS)

Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.

2017-02-01

Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10-37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.

Variations in understanding the drug-prescribing process: a qualitative study among Swedish GPs.

PubMed

Rahmner, Pia Bastholm; Gustafsson, Lars L; Larsson, Jan; Rosenqvist, Urban; Tomson, Göran; Holmström, Inger

2009-04-01

A majority of doctor-patient meetings result in the patient getting a prescription. This underlines the need for a high-quality prescription process. While studies have been made on single therapeutic drug groups, a complete study of the physicians' general thought process that comprises the prescription of all drugs still remains to be made. To identify variations in ways of understanding drug prescribing among GPs. A descriptive qualitative study was conducted with 20 Swedish physicians. Informants were recruited purposively and their understandings about prescribing were studied in semi-structured interviews. Data were analysed using a phenomenographic approach. Five categories were identified as follows: (A) GP prescribed safe, reliable and well-documented drugs for obvious complaints; (B) GP sought to convince the patient of the most effective drug treatment; (C) GP chose the best drug treatment taking into consideration the patient's entire life situation; (D) GP used clinical judgement and close follow-up to minimize unnecessary drug prescribing and (E) GP prescribed drugs which are cheap for society and environmentally friendly. The categories are interrelated, but have different foci: the biomedical, the patient and the society. Each GP had more than one view but none included all five. The findings also indicate that complexity increases when a drug is prescribed for primary or secondary prevention. GPs understand prescribing differently despite similar external circumstances. The most significant factor to influence prescribing behaviour was the physician's patient relation approach. GPs may need to reflect on difficulties they face while prescribing to enhance their understandings.

Antibiotic prescriptions for upper respiratory tract infection in Japan.

PubMed

Higashi, Takahiro; Fukuhara, Shunichi

2009-01-01

The overuse of antibiotics results in the unnecessary spread of resistant strains. A common setting for antibiotic overuse is in the treatment of upper respiratory tract infections (URIs), which are predominantly due to viruses. To investigate the type and frequency of antibiotic prescription for URI without apparent bacterial infection in Japan, based on both visits and facilities. Cross-sectional analysis of insurance claims submitted to an employer-sponsored health insurance plan in Japan between January and March, 2005 for diagnoses of URI. Claims having a potentially valid reason for antibiotic prescription (e.g., secondary diagnosis of pneumonia) were excluded. Antibiotics prescribed for these URI visits. From a total of 24,134 claims, 2,577 claims (non-bacterial URI, one visit per claim) were analyzed; antibiotics were prescribed in 60% of these visits. Third-generation cephalosporins were the most commonly-prescribed drug class (46%), followed by macrolides (27%) and quinolones (16%). In general, visits to physician offices were more likely to result in an antibiotic prescription than visits to hospital outpatient clinics. No statistically significant difference was identified among hospital types, including private and public ownership or teaching hospital status. Analysis of the frequency of antibiotic prescription by facility revealed two peaks in distribution, with one group prescribing to about 90% of URI patients and the second appearing to prescribe to about 40% of patients. Antibiotics are frequently prescribed to URI patients in Japan. Although overuse results from the difficulty in accurately distinguishing viral from bacterial URIs, some facilities appear to attempt to differentiate the underlying cause of the URI while others do not.

Potentially inappropriate medication prescribing is associated with socioeconomic factors: a spatial analysis in the French Nord-Pas-de-Calais Region.

PubMed

Beuscart, Jean-Baptiste; Genin, Michael; Dupont, Corrine; Verloop, David; Duhamel, Alain; Defebvre, Marguerite-Marie; Puisieux, François

2017-07-01

potentially inappropriate medication (PIM) prescribing is common in older people and leads to adverse events and hospital admissions. to determine whether prevalence of PIM prescribing varies according to healthcare supply and socioeconomic status. all prescriptions dispensed at community pharmacies for patients aged 75 and older between 1 January  and 31 March 2012 were retrieved from French Health Insurance Information System of the Nord-Pas-de-Calais Region for patients affiliated to the Social Security scheme. PIM was defined according to the French list of Laroche. The geographic distribution of PIM prescribing in this area was analysed using spatial scan statistics. overall, 65.6% (n = 207,979) of people aged 75 years and over living in the Nord-Pas-de-Calais Region were included. Among them, 32.6% (n = 67,863) received at least one PIM. The spatial analysis identified 16 and 10 clusters of municipalities with a high and a low prevalence of PIM prescribing, respectively. Municipalities with a low prevalence of PIM were characterised by a high socioeconomic status whereas those with a high prevalence of PIM were mainly characterised by a low socioeconomic status, such as a high unemployment rate and low household incomes. Markers of healthcare supply were weakly associated with high or low prevalence clusters. significant geographic variation in PIM prescribing was observed in the study territory and was mainly associated with socioeconomic factors. © The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com

Evaluation of a targeted prescriber education intervention on emergency department discharge oxycodone prescribing.

PubMed

Donaldson, Síne R; Harding, Andrew M; Taylor, Simone E; Vally, Hassan; Greene, Shaun L

2017-08-01

The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic (OA) prescribing. A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non-OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability. A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% (P = 0.04) and those receiving follow-up advice increased from 61 to 94% (P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% (P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg (P = 0.04). Non-OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients (P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment. A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial.

PubMed

Formoso, Giulio; Paltrinieri, Barbara; Marata, Anna Maria; Gagliotti, Carlo; Pan, Angelo; Moro, Maria Luisa; Capelli, Oreste; Magrini, Nicola

2013-09-12

To test the hypothesis that a multifaceted, local public campaign could be feasible and influence antibiotic prescribing for outpatients. Community level, controlled, non-randomised trial. Provinces of Modena and Parma in Emilia-Romagna, northern Italy, November 2011 to February 2012. 1,150,000 residents of Modena and Parma (intervention group) and 3,250,000 residents in provinces in the same region but where no campaign had been implemented (control group). Campaign materials (mainly posters, brochures, and advertisements on local media, plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists). General practitioners and paediatricians in the intervention area participated in designing the campaign messages. Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months, measured as defined daily doses per 1000 inhabitants/day, using health districts as the unit of analysis. Antibiotic prescribing was reduced in the intervention area compared with control area (-4.3%, 95% confidence interval -7.1% to -1.5%). This result was robust to "sensitivity analysis" modifying the baseline period from two months (main analysis) to one month. A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase, consistent with the content of the newsletter on antibiotic resistance directed at health professionals. The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period (main analysis), but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis. Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas. A local low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population's knowledge and attitudes about antibiotic resistance. ClinicalTrials.gov NCT01604096.

Organ Doses Associated with Partial-Body Irradiation with 2.5% Bone Marrow Sparing of the Non-Human Primate: A Retrospective Study.

PubMed

Prado, C; MacVittie, T J; Bennett, A W; Kazi, A; Farese, A M; Prado, K

2017-12-01

A partial-body irradiation model with approximately 2.5% bone marrow sparing (PBI/BM2.5) was established to determine the radiation dose-response relationships for the prolonged and delayed multi-organ effects of acute radiation exposure. Historically, doses reported to the entire body were assumed to be equal to the prescribed dose at some defined calculation point, and the dose-response relationship for multi-organ injury has been defined relative to the prescribed dose being delivered at this point, e.g., to a point at mid-depth at the level of the xiphoid of the non-human primate (NHP). In this retrospective-dose study, the true distribution of dose within the major organs of the NHP was evaluated, and these doses were related to that at the traditional dose-prescription point. Male rhesus macaques were exposed using the PBI/BM2.5 protocol to a prescribed dose of 10 Gy using 6-MV linear accelerator photons at a rate of 0.80 Gy/min. Point and organ doses were calculated for each NHP from computed tomography (CT) scans using heterogeneous density data. The prescribed dose of 10.0 Gy to a point at midline tissue assuming homogeneous media resulted in 10.28 Gy delivered to the prescription point when calculated using the heterogeneous CT volume of the NHP. Respective mean organ doses to the volumes of nine organs, including the heart, lung, bowel and kidney, were computed. With modern treatment planning systems, utilizing a three-dimensional reconstruction of the NHP's CT images to account for the variations in body shape and size, and using density corrections for each of the tissue types, bone, water, muscle and air, accurate determination of the differences in dose to the NHP can be achieved. Dose and volume statistics can be ascertained for any body structure or organ that has been defined using contouring tools in the planning system. Analysis of the dose delivered to critical organs relative to the total-body target dose will permit a more definitive analysis of organ-specific effects and their respective influence in multiple organ injury.

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.

PubMed

Nanji, Karen C; Rothschild, Jeffrey M; Boehne, Jennifer J; Keohane, Carol A; Ash, Joan S; Poon, Eric G

2014-01-01

Electronic prescribing systems have often been promoted as a tool for reducing medication errors and adverse drug events. Recent evidence has revealed that adoption of electronic prescribing systems can lead to unintended consequences such as the introduction of new errors. The purpose of this study is to identify and characterize the unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in an outpatient pharmacy. A multidisciplinary team conducted direct observations of workflow in an independent pharmacy and semi-structured interviews with pharmacy staff members about their perceptions of the unrealized potential and residual consequences of electronic prescribing systems. We used qualitative methods to iteratively analyze text data using a grounded theory approach, and derive a list of major themes and subthemes related to the unrealized potential and residual consequences of electronic prescribing. We identified the following five themes: Communication, workflow disruption, cost, technology, and opportunity for new errors. These contained 26 unique subthemes representing different facets of our observations and the pharmacy staff's perceptions of the unrealized potential and residual consequences of electronic prescribing. We offer targeted solutions to improve electronic prescribing systems by addressing the unrealized potential and residual consequences that we identified. These recommendations may be applied not only to improve staff perceptions of electronic prescribing systems but also to improve the design and/or selection of these systems in order to optimize communication and workflow within pharmacies while minimizing both cost and the potential for the introduction of new errors.

A qualitative study of GPs' and PCO stakeholders' views on the importance and influence of cost on prescribing.

PubMed

Prosser, Helen; Walley, Tom

2005-03-01

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders. The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs' resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

The use of cognitive continuum theory and patient scenarios to explore nurse prescribers' pharmacological knowledge and decision-making.

PubMed

Offredy, Maxine; Kendall, Sally; Goodman, Claire

2008-06-01

Nurses have been involved in prescribing in England since 1996, and to date over 41,000 nurses are registered with the Nursing and Midwifery Council as prescribers. The majority of evaluative research on nurse prescribing is descriptive and relies on self-report and assessment of patient satisfaction. To explore and test nurse prescribers' pharmacological knowledge and decision-making. An exploratory approach to test the usefulness of patient scenarios in addressing the reasons why nurses decide whether or not to prescribe was utilised. Semi-structured interviews with nurse prescribers using patient scenarios were used as proxy methods of assessment of how nurses made their prescribing decisions. Two primary care trusts in the southeast of England were the settings for this study. Purposive sampling to ensure there was a mixed group of prescribers was used to enable detailed exploration of the research objectives and to obtain in-depth understanding of the complex activities involved in nurse prescribing. Interviews and case scenarios. The use of cognitive continuum theory guided the analysis. The majority of participants were unable to identify the issues involved in all the scenarios; they also failed to provide an acceptable solution to the problem, suggesting that they would refer the patient to the general practitioner. A similar number described themselves as 'very confident' while seven participants felt that they were 'not confident' in dealing with medication issues, four of whom were practising prescribing. The effects of social and institutional factors are important in the decision-making process. The lack of appropriate pharmacological knowledge coupled with lack of confidence in prescribing was demonstrated. The scenarios used in this study indicate that nurses are perhaps knowledgeable in their small area of practise but flounder outside this. Further research could be conducted with a larger sample and with more scenarios to explore the decision-making and the pharmacological knowledge base of nurse prescribers, particularly in the light of government policy to extend prescribing rights to non-medical prescribers, including pharmacists.

Prescribing patterns of non-steroidal anti-inflammatory drugs in chronic kidney disease patients in the South African private sector.

PubMed

Meuwesen, Willem P; du Plessis, Jesslee M; Burger, Johanita R; Lubbe, Martie S; Cockeran, Marike

2016-08-01

Background Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used pharmaceutical agents worldwide. NSAIDs are considered nephrotoxic and should therefore be used with caution or be avoided completely in high risk patients, such as chronic kidney disease (CKD) patients. Objective This study aimed to investigate the prescribing of NSAIDs in CKD patients in order to generate awareness and improve the outcome of these patients. Setting The study was conducted using medicine claims data in the private health sector of South Africa. Method A descriptive, quantitative study was performed, using retrospective data obtained from a Pharmaceutical Benefit Management company. Data from 1 January 2009 to 31 December 2013 were analysed. The study population consisted of all patients with an ICD-10 code for a CKD (N18), in association with a paid claim for an NSAID. Main outcome measure The stratification of NSAID prescribing volume among the CKD population in terms of gender, age, NSAID type, dosage and prescriber type. Results The prescribing of NSAIDs in CKD patients varied between 26 and 40 % over the 5 year study period. No association between gender and CKD patients who received NSAIDs versus those who did not was found, with p > 0.05 and Cramer's V < 0.1 for each year of the study. The association between age groups and CKD patients who received NSAIDs versus those who did not was statistically significant, but practically weak (p < 0.05; Cramer's V ≥ 0.1). Most NSAID prescriptions (52-63 %) were for patients aged 35-64 years. Diclofenac (34.25 %) was the single most frequently prescribed NSAID, but the COX-2-inhibitors (celecoxib, meloxicam and etoricoxib) were the preferred NSAID class to be prescribed. The majority (61.6 %) of the NSAIDs were prescribed by general medical practitioners in dosages meeting and even exceeding the recommended daily dosage of patients with normal kidney function. Conclusions Even though NSAIDs are regarded as nephrotoxic drugs, they are still being prescribed to at-risk CKD patients, in particular, the elderly.

29 CFR 1910.1001 - Asbestos.

Code of Federal Regulations, 2010 CFR

2010-07-01

.... The designation of a material as “PACM” may be rebutted pursuant to paragraph (j)(8) of this section... level as demonstrated by a statistically valid protocol; and (C) The equivalent method is documented and... PACM are in excess of the TWA and/or excursion limit prescribed in paragraph (c) of this section. (2...

29 CFR 1910.1001 - Asbestos.

Code of Federal Regulations, 2011 CFR

2011-07-01

.... The designation of a material as “PACM” may be rebutted pursuant to paragraph (j)(8) of this section... level as demonstrated by a statistically valid protocol; and (C) The equivalent method is documented and... PACM are in excess of the TWA and/or excursion limit prescribed in paragraph (c) of this section. (2...

Laboratory Aspects of Blood Lipids

NASA Technical Reports Server (NTRS)

Townsend, F. M.

1970-01-01

Classification of blood hyperlipemias by electrophoresis or ultracentrifugation according to density fraction is described and therapeutic measures for humans with hyperlipoproteinemia are outlined. The statistically significant relationship between high serum cholesterol levels and incidence of coronary disease prescribes restricted caloric intake or physical exercise to burn excess calories as preventive measures.

48 CFR 52.219-22 - Small Disadvantaged Business Status.

Code of Federal Regulations, 2010 CFR

2010-10-01

.... Status as a small business and status as a small disadvantaged business for general statistical purposes... Business Status. 52.219-22 Section 52.219-22 Federal Acquisition Regulations System FEDERAL ACQUISITION... Clauses 52.219-22 Small Disadvantaged Business Status. As prescribed in 19.308(b), insert the following...

Predicting post-fire change in West Virginia, USA from remotely-sensed data

Treesearch

Michael P. Strager; Melissa Thomas-Van Gundy; Aaron E. Maxwell

2016-01-01

Prescribed burning is used in West Virginia, USA to return the important disturbance process of fire to oak and oak-pine forests. Species composition and structure are often the main goals for re-establishing fire with less emphasis on fuel reduction or reducing catastrophic wildfire. In planning prescribed fires land managers could benefit from the ability to predict...

Comparing the effectiveness of thinning and prescribed fire for modifying structure in dry coniferous forests

Treesearch

Richy J. Harrod; Nicholas A. Povak; David W. Peterson

2007-01-01

Forest thinning and prescribed fires are the main practices used by managers to address concerns over ecosystem degradation and severe wildland fire potential in dry forests of the Western United States. There is some debate, however, about treatment effectiveness in meeting management objectives as well as their ecological consequences. This study assesses the...

Time series analysis of forest carbon dynamics: recovery of Pinus palustris physiology following a prescribed fire

Treesearch

G. Starr; C. L. Staudhammer; H. W. Loescher; R. Mitchell; A. Whelan; J. K. Hiers; J. J. O’Brien

2015-01-01

Frequency and intensity of fire determines the structure and regulates the function of savanna ecosystems worldwide, yet our understanding of prescribed fire impacts on carbon in these systems is rudimentary. We combined eddy covariance (EC) techniques and fuel consumption plots to examine the short-term response of longleaf pine forest carbon dynamics to one...

Assessment of Antibiotic Utilization Pattern in Treatment of Acute Diarrhoea Diseases in Bishoftu General Hospital, Oromia Ethiopia.

PubMed

Tulu, Selamawit; Tadesse, Tarekegne; Alemayehu Gube, Addisu

2018-01-01

Majority of acute diarrhoeal diseases are self-limiting and do not require routine treatment. Treatment with empirical antimicrobials is recommended only for dysenteric and invasive bacterial diarrhoea. Irrational use of antibiotics in treatment of acute diarrhoea is common in clinical practice worldwide. This study was carried out to assess the pattern of antibiotic use for acute diarrhoeal diseases in Bishoftu General Hospital, East Shewa Ethiopia. Institution based cross-sectional study was conducted from April 1 to April 30, 2016. Data were collected retrospectively from patients treated for diarrhoeal diseases from January 2015 to December 2015 using structured questionnaires and entered into SPSS (IBM 20) and descriptive statistics was carried out. Among the 303 patients, 51.2% were males and 48.8% were females. Of them, 62% were children under five years. Two hundred sixty three (86.8%) patients received eight different types of antibiotics and cotrimoxazole (178 patients, 58.7%) was the most prescribed antibiotics, followed by ciprofloxacin (33, 10.9%) and amoxicillin (14, 4.6%). Based on the presence of blood in stools, 14.5% of cases were of invasive bacterial type. According to the recommendations of WHO, the rate of overuse of antibiotics was 72.3%. This study revealed that there was high overuse of antibiotics for both adults and children under five with acute diarrhoea in Bishoftu General Hospital. And Cotrimoxazole was the most prescribed antibiotic.

Patient perspectives on choosing buprenorphine over methadone in an urban, equal-access system.

PubMed

Gryczynski, Jan; Jaffe, Jerome H; Schwartz, Robert P; Dušek, Kristi A; Gugsa, Nishan; Monroe, Cristin L; O'Grady, Kevin E; Olsen, Yngvild K; Mitchell, Shannon Gwin

2013-01-01

Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly funded treatment sector. This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n = 80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%), and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed "street buprenorphine" were a central factor in participants' decisions to seek buprenorphine treatment. Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. This study characterizes important decision factors that underlie patients' selection of buprenorphine over methadone treatment. Copyright © American Academy of Addiction Psychiatry.

Patient Perspectives on Choosing Buprenorphine over Methadone in an Urban Equal Access System

PubMed Central

Gryczynski, Jan; Jaffe, Jerome H.; Schwartz, Robert P.; Dušek, Kristi A.; Gugsa, Nishan; Monroe, Cristin L.; O'Grady, Kevin E.; Olsen, Yngvild K.; Mitchell, Shannon Gwin

2014-01-01

Background Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly-funded treatment sector. Objectives This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. Methods This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n=80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%) and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Results Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed “street buprenorphine” were a central factor in participants’ decisions to seek buprenorphine treatment. Conclusions Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. Scientific Significance This study characterizes important decision factors that underlie patients’ selection of buprenorphine over methadone treatment. PMID:23617873

[Impact of an |A|B|S|-training initiative on |A|B|S|-structural quality of participating hospitals].

PubMed

Christoph, Anna; Ehm, Christine; de With, Katja

2015-01-01

The "ABS-training initiative" was funded by the German Ministry of Health as part of the German Antimicrobial Resistance Strategy (Deutsche Antibiotika-Resistenz-Strategie, DART) from 2009 until early 2014. The initiative was designed for clinicians and clinical pharmacists and contains several training units covering antiinfectives, infectious diseases and ABS strategies including the conduction of a research project at the participants' hospital. Participants who complete the four-weeks training initiative will become a certified "ABS Expert". 281 ABS Experts were asked to take part in a survey (staff for ABS, surveillance data about agents and consumption, ABS activity) to estimate the influence of the ABS-training initiative on the ABS-structural quality. The evaluation was performed using GrafStat (V 4.255), statistical software package for the evaluation of surveys. Ninety-two ABS Experts representing 92 hospitals participated in a questionnaire-based survey before and after completing the training initiative. Forty (44 %) hospitals appointed an ABS representative (+22 %) after completing the training initiative. Antibiotic surveillance data available as a report increased from 34 (40 %) to 54 (60 %) and correct data presentation (DDD or RDD/100 days) from 7 (8 %) to 40 (43 %). Proactive auditing of antiinfective prescribing improved from 54 (60 %) to 71 (78 %) in intensive care units, and from 28 (31 %) to 53 (58 %) on normal wards. Availability of local guidelines increased from 36 (39 %) to 52 (57 %). The "ABS Training Initiative" had a positive impact on ABS-structural quality regarding nomination of ABS-teams, surveillance data of antibiotic consumption, implementation of proactive auditing of antiinfective prescribing and availability of local guidelines. However, there is optimization potential in many sectors. The short time period between pre- and post-assessment and the ongoing personnel or time constraints need to be taken into account. Copyright © 2015. Published by Elsevier GmbH.

Mental health issues among college students: who gets referred for psychopharmacology evaluation?

PubMed

Kirsch, Daniel J; Doerfler, Leonard A; Truong, Debbie

2015-01-01

To describe diagnostic and psychotropic medication prescription characteristics among college students referred by college counseling centers for psychopharmacologic evaluation. Participants were 540 college students referred by 6 college counseling centers in Massachusetts between November 2005 and May 2011. Students completed self-report measures of depression, anxiety, suicidal ideation and attempts, and substance use. Information regarding DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) diagnosis, previous history of medication prescription, and current psychotropic medication(s) prescribed by the consulting psychiatrist was obtained from medical records. Depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD) were the most common psychiatric problems identified in students. Half of these students had been prescribed mediation prior to evaluation. Antidepressant medication was the most frequently prescribed medication. A large proportion of students reported previous thoughts of suicide, and 12% had made at least 1 suicide attempt. Depression, anxiety, and ADHD are common among students referred by college counseling centers for medication evaluation and treatment.

Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia.

PubMed

Wood, Susan F; Podrasky, Joanna; McMonagle, Meghan A; Raveendran, Janani; Bysshe, Tyler; Hogenmiller, Alycia; Fugh-Berman, Adriane

2017-01-01

Gifts from pharmaceutical companies are believed to influence prescribing behavior, but few studies have addressed the association between industry gifts to physicians and drug costs, prescription volume, or preference for generic drugs. Even less research addresses the effect of gifts on the prescribing behavior of nurse practitioners (NPs), physician assistants (PAs), and podiatrists. To analyze the association between gifts provided by pharmaceutical companies to individual prescribers in Washington DC and the number of prescriptions, cost of prescriptions, and proportion of branded prescriptions for each prescriber. Gifts data from the District of Columbia's (DC) AccessRx program and the federal Center for Medicare and Medicaid Services (CMS) Open Payments program were analyzed with claims data from the CMS 2013 Medicare Provider Utilization and Payment Data. Washington DC, 2013. Physicians, nurse practitioners, physician assistants, podiatrists, and other licensed Medicare Part D prescribers who participated in Medicare Part D (a Federal prescription drug program that covers patients over age 65 or who are disabled). Gifts to healthcare prescribers (including cash, meals, and ownership interests) from pharmaceutical companies. Average number of Medicare Part D claims per prescriber, number of claims per patient, cost per claim, and proportion of branded claims. In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. In six specialties (General Internal Medicine, Family Medicine, Obstetrics/Gynecology, Urology, Ophthalmology, and Dermatology), gifts were associated with a significantly increased average cost of claims. For Internal Medicine, Family Medicine, and Ophthalmology, gifts were associated with more branded claims. Gift acceptance was associated with increased average cost per claim for PAs and NPs. Gift acceptance was also associated with higher proportion of branded claims for PAs but not NPs. Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups. All differences were statistically significant (p<0.05). Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors. Our study confirms and expands on previous work showing that industry gifts are associated with more expensive prescriptions and more branded prescriptions. Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned.

14 CFR 183.29 - Designated engineering representatives.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 3 2012-01-01 2012-01-01 false Designated engineering representatives. 183... § 183.29 Designated engineering representatives. (a) A structural engineering representative may approve structural engineering information and other structural considerations within limits prescribed by and under...

14 CFR 183.29 - Designated engineering representatives.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 3 2014-01-01 2014-01-01 false Designated engineering representatives. 183... § 183.29 Designated engineering representatives. (a) A structural engineering representative may approve structural engineering information and other structural considerations within limits prescribed by and under...

14 CFR 183.29 - Designated engineering representatives.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 3 2011-01-01 2011-01-01 false Designated engineering representatives. 183... § 183.29 Designated engineering representatives. (a) A structural engineering representative may approve structural engineering information and other structural considerations within limits prescribed by and under...

14 CFR 183.29 - Designated engineering representatives.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 3 2013-01-01 2013-01-01 false Designated engineering representatives. 183... § 183.29 Designated engineering representatives. (a) A structural engineering representative may approve structural engineering information and other structural considerations within limits prescribed by and under...

14 CFR 183.29 - Designated engineering representatives.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 3 2010-01-01 2010-01-01 false Designated engineering representatives. 183... § 183.29 Designated engineering representatives. (a) A structural engineering representative may approve structural engineering information and other structural considerations within limits prescribed by and under...

What do mental health workers in the bush think about mental health nurse prescribing? A cross-sectional study.

PubMed

Muyambi, Kuda; McPhail, Ruth; Cronin, Kathryn; Gillam, Marianne; Martinez, Lee; Dennis, Shaun; Bressington, Daniel; Gray, Richard; Jones, Martin

2018-06-04

Relatively few psychiatrists live and work in rural South Australia. The rural GP is an essential component of support for people with mental health problems. However, considerable GP maldistribution between rural and metropolitan Australia still exists. Thus, accessing health services, including medication, becomes challenging for rural communities. Extending mental health nurse prescribing could be a strategy to build additional capacity to complement the GPs and psychiatrists who practice in rural South Australia. Until now, no studies have examined mental health workers' attitudes towards nurse prescribing in rural Australia. To examine the attitudes of rural and remote South Australian mental health workers about mental health nurse prescribing. A cross-sectional survey assessing mental health workers' attitudes to mental health nurse prescribing. The study was conducted across South Australia, excluding metropolitan Adelaide. Mental health workers employed by the Country Health South Australia Local Health Network for Mental Health. Of the 289 potential participants, 93 (32%) responded and were included in this study. All the respondents reported positive attitudes towards mental health nurse prescribing. However, they expressed concerns about safety, educational preparation and supervision structures. The attitudes of rural South Australian mental health workers are not a barrier to mental health nurse prescribing. The implementation and sustainability of mental health nurse prescribing will require additional staff training in psychopharmacology and a governance framework to assure quality and safety. Policy-makers need to focus their attention on the uptake of mental health nurse prescribing in parts of Australia that struggle to attract and retain psychiatrists. © 2018 National Rural Health Alliance Ltd.

Short-term stem mortality of 10 deciduous broadleaved species following prescribed burning in upland forests of the southern US

Treesearch

Tara L. Keyser; Virginia L. McDaniel; Robert N. Klein; Dan G. Drees; Jesse A. Burton; Melissa M. Forder

2018-01-01

In upland forests of the southern US, management is increasingly focussed on the restoration and maintenance of resilient structures and species compositions, with prescribed burning being the primary tool used to achieve these goals and objectives. In this study, we utilised an extensive dataset comprising 91 burn units and 210 plots across 13 National Park Service...

Thinning and prescribed fire effects on overstory tree and snag structure in dry coniferous forests of the interior Pacific Northwest

Treesearch

Richy J. Harrod; David W. Peterson; Nicholas A. Povak; Erich Kyle Dodson

2009-01-01

Forest thinning and prescribed fires are practices used by managers to address concerns over ecosystem degradation and severe wildland fire potential in dry forests. There is some debate, however, about treatment effectiveness in meeting management objectives as well as their ecological consequences. The purpose of this study was to assess changes to forest stand...

Blacks Mountain Experimental Forest: bark beetle responses to differences in forest structure and the application of prescribed fire in interior ponderosa pine

Treesearch

Christopher J. Fettig; Robert R. Borys; Stephen R. McKelvey; Christopher P. Dabney

2008-01-01

Mechanical thinning and the application of prescribed fire are commonly used tools in the restoration of fire-adapted forest ecosystems. However, few studies have explored their effects on subsequent amounts of bark beetle caused tree mortality in interior ponderosa pine, Pinus ponderosa Dougl. ex P. & C. Laws. var. ponderosa. In...

Effects of low intensity prescribed fires on ponderosa pine forests in wilderness areas of Zion National Park, Utah

Treesearch

Henry V. Bastian

2001-01-01

Vegetation and fuel loading plots were monitored and sampled in wilderness areas treated with prescribed fire. Changes in ponderosa pine (Pinus ponderosa) forest structure tree species and fuel loading are presented. Plots were randomly stratified and established in burn units in 1995. Preliminary analysis of nine plots 2 years after burning show litter was reduced 54....

Long-term effects of dormant-season prescribed fire on plant community diversity, structure and productivity in a longleaf pine wiregrass ecosystem

Treesearch

Dale G. Brockway; Clifford E. Lewis

1997-01-01

A flatwoods longleaf pine wiregrass ecosystem, which regenerated naturally following wildfire in 1942, on the Coastal Plain of southern Georgia was treated over a period of four decades with prescribed fire at annual, biennial and triennial intervals during the winter dormant season. Burning caused substantial changes in the understory plant community, with significant...

Assessing the regeneration potential of productive mixed-hardwood stands following single and repeated prescribed fire

Treesearch

Tara L. Keyser; Katie Greenberg; Dean Simon; Gordon S. Warburton

2016-01-01

Management efforts on public lands across the southern Appalachian Mountains are increasingly focused on the creation, maintenance, and/or restoration of resilient structures and species compositions, with prescribed burning being the primary tool by which many of these restoration efforts are conducted. In this study, we use regeneration data from a study designed to...

The influence of fire on the assemblage structure of foraging birds in grasslands of the Serra da Canastra National Park, Brazil.

PubMed

Reis, Matheus G; Fieker, Carolline Z; Dias, Manoel M

2016-05-13

Grasslands are the most threatened physiognomies of the Cerrado biome (Brazilian savanna), a biodiversity hotspot with conservation as a priority. The Serra da Canastra National Park protects the most important remnants of the Cerrado's southern grasslands, which are under strong anthropogenic pressure. The present study describes the structure of bird assemblages that directly use food resources in burned areas, comparing areas affected by natural fire to the areas where controlled fires were set (a management strategy to combat arson). The tested null hypothesis was that different bird assemblages are structured in a similar manner, regardless of the post-fire period or assessed area. Between December/2012 and January/2015, 92 species were recorded foraging in the study areas. The results indicate that both types of burnings triggered profound and immediate changes in bird assemblages, increasing the number of species and individuals. Natural fires exhibited a more significant influence on the structure (diversity and dominance) than prescribed burnings. Nevertheless, all the differences were no longer noticeable after a relatively short time interval of 2-3 months after prescribed burnings and 3-4 after natural fires. The findings may help the understanding of prescribed burnings as a management strategy for bird conservation in grasslands.

Structural, electronic, and dynamical properties of liquid water by ab initio molecular dynamics based on SCAN functional within the canonical ensemble

NASA Astrophysics Data System (ADS)

Zheng, Lixin; Chen, Mohan; Sun, Zhaoru; Ko, Hsin-Yu; Santra, Biswajit; Dhuvad, Pratikkumar; Wu, Xifan

2018-04-01

We perform ab initio molecular dynamics (AIMD) simulation of liquid water in the canonical ensemble at ambient conditions using the strongly constrained and appropriately normed (SCAN) meta-generalized-gradient approximation (GGA) functional approximation and carry out systematic comparisons with the results obtained from the GGA-level Perdew-Burke-Ernzerhof (PBE) functional and Tkatchenko-Scheffler van der Waals (vdW) dispersion correction inclusive PBE functional. We analyze various properties of liquid water including radial distribution functions, oxygen-oxygen-oxygen triplet angular distribution, tetrahedrality, hydrogen bonds, diffusion coefficients, ring statistics, density of states, band gaps, and dipole moments. We find that the SCAN functional is generally more accurate than the other two functionals for liquid water by not only capturing the intermediate-range vdW interactions but also mitigating the overly strong hydrogen bonds prescribed in PBE simulations. We also compare the results of SCAN-based AIMD simulations in the canonical and isothermal-isobaric ensembles. Our results suggest that SCAN provides a reliable description for most structural, electronic, and dynamical properties in liquid water.

26 CFR 1.1446-5 - Tiered partnership structures.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 26 Internal Revenue 12 2010-04-01 2010-04-01 false Tiered partnership structures. 1.1446-5 Section...-Free Covenant Bonds § 1.1446-5 Tiered partnership structures. (a) In general. The rules of this section... prescribes rules applicable to a publicly traded partnership in a tiered partnership structure. Paragraph (e...

Reducing Prescriptions of Long-Acting Benzodiazepine Drugs in Denmark: A Descriptive Analysis of Nationwide Prescriptions during a 10-Year Period.

PubMed

Eriksen, Sophie Isabel; Bjerrum, Lars

2015-06-01

Prolonged consumption of benzodiazepine drugs (BZD) and benzodiazepine receptor agonists (zolpidem, zaleplon, zopiclone; altogether Z drugs) is related to potential physiological and psychological dependence along with other adverse effects. This study aimed to analyse the prescribing of long-acting BZD (half-life >10 hr), compared to short-acting BZD in Denmark during a 10-year period. Descriptive analysis of total sales data from the Danish Register of Medicinal Product Statistics, to individuals in the primary healthcare sector, of all BZD and Z drugs in the period of 2003-2013. Prescription data derive from all community and hospital pharmacies in Denmark. The prescribing of long-acting BZD was reduced from 25.8 defined daily doses (DDD)/1000 inhabitants/day in 2003 to 8.8 DDD/1000 inhabitants/day in 2013, a relative reduction of 66%. The prescribing of short-acting BZD was reduced from 26.1 DDD/1000 inhabitants/day in 2003 to 16.4 DDD/1000 inhabitants/day in 2013, a relative reduction of 37%. Prescription data in this study did not include information about indications for initiating treatments. In addition, due to compliance problems, some of the prescribed drugs may not have been consumed according to the prescription. The observed reduction in BZD use was correlated to the introduction of new national guidelines on prescription of addictive drugs, but this study was not designed to detect a causal relationship. The prescribing of long-acting BZD decreased considerably more than the prescribing of short-acting BZD in the 10-year period. © 2014 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach

PubMed Central

Yogo, Norihiro; Shihadeh, Katherine; Young, Heather; Calcaterra, Susan; Knepper, Bryan C; Burman, William J; Mehler, Philip S; Jenkins, Timothy C

2017-01-01

Objective For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Post-discharge therapy is often unnecessarily broad-spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. Design Single center, quasi-experimental retrospective cohort study. Methods Patients prescribed oral antibiotics at hospital discharge before (July 2012 – June 2013) and after (October 2014 – February 2015) an intervention consisting of: 1) institutional guidance for oral step-down antibiotic selection and duration of therapy, and 2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The primary outcomes were total prescribed duration of therapy and use of antibiotics with broad gram-negative activity (fluoroquinolones or amoxicillin-clavulanate). Results 300 cases from the pre-intervention period and 200 from the intervention period were included. Compared with the pre-intervention period, use of antibiotics with broad gramnegative activity decreased during the intervention (51% vs 40%, p = 0.02), particularly fluoroquinolones (38% vs 25%, p = 0.002). The difference in total duration of therapy did not reach statistical significance (10 days [interquartile range (IQR) 7–13] vs 9 [IQR 6–13], p = 0.13); however, the duration prescribed at discharge declined from 6 days (IQR 4–10) to 5 (IQR 3–7) (p = 0.003). During the intervention, there was a non-significant increase in the overall appropriateness of discharge prescriptions (52% vs 66%, p = 0.15). Conclusions A multifaceted intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of antibiotics with broad gram-negative activity and shorter post-hospital treatment durations. PMID:28260538

Effects of information framing on the intentions of family physicians to prescribe long-term hormone replacement therapy.

PubMed

Nikolajevic-Sarunac, J; Henry, D A; O'Connell, D L; Robertson, J

1999-10-01

To determine whether the way in which information on benefits and harms of long-term hormone replacement therapy (HRT) is presented influences family physicians' intentions to prescribe this treatment. Family physicians were randomized to receive information on treatment outcomes expressed in relative terms, or as the number needing to be treated (NNT) with HRT to prevent or cause an event. A control group received no information. Primary care. Family physicians practicing in the Hunter Valley, New South Wales, Australia. Estimates of the impact of long-term HRT on risk of coronary events, hip fractures, and breast cancer were summarized as relative (proportional) decreases or increases in risk, or as NNT. Intention to prescribe HRT for seven hypothetical patients was measured on Likert scales. Of 389 family physicians working in the Hunter Valley, 243 completed the baseline survey and 215 participated in the randomized trial. Baseline intention to prescribe varied across patients-it was highest in the presence of risk factors for hip fracture, but coexisting risk factors for breast cancer had a strong negative influence. Overall, a larger proportion of subjects receiving information expressed as NNT had reduced intentions, and a smaller proportion had increased intentions to prescribe HRT than those receiving the information expressed in relative terms, or the control group. However, the differences were small and only reached statistical significance for three hypothetical patients. Framing effects were minimal when the hypothetical patient had coexisting risk factors for breast cancer. Information framing had some effect on family physicians' intentions to prescribe HRT, but the effects were smaller than those previously reported, and they were modified by the presence of serious potential adverse treatment effects.

Effects of Information Framing on the Intentions of Family Physicians to Prescribe Long-Term Hormone Replacement Therapy

PubMed Central

Nikolajevic-Sarunac, Jasminka; Henry, David A; Henry, David A; O'Connell, Dianne L; Robertson, Jane; Robertson, Jane

1999-01-01

OBJECTIVE To determine whether the way in which information on benefits and harms of long-term hormone replacement therapy (HRT) is presented influences family physicians' intentions to prescribe this treatment. DESIGN Family physicians were randomized to receive information on treatment outcomes expressed in relative terms, or as the number needing to be treated (NNT) with HRT to prevent or cause an event. A control group received no information. SETTING Primary care. PARTICIPANTS Family physicians practicing in the Hunter Valley, New South Wales, Australia. INTERVENTION Estimates of the impact of long-term HRT on risk of coronary events, hip fractures, and breast cancer were summarized as relative (proportional) decreases or increases in risk, or as NNT. MEASUREMENTS AND MAIN RESULTS Intention to prescribe HRT for seven hypothetical patients was measured on Likert scales. Of 389 family physicians working in the Hunter Valley, 243 completed the baseline survey and 215 participated in the randomized trial. Baseline intention to prescribe varied across patients—it was highest in the presence of risk factors for hip fracture, but coexisting risk factors for breast cancer had a strong negative influence. Overall, a larger proportion of subjects receiving information expressed as NNT had reduced intentions, and a smaller proportion had increased intentions to prescribe HRT than those receiving the information expressed in relative terms, or the control group. However, the differences were small and only reached statistical significance for three hypothetical patients. Framing effects were minimal when the hypothetical patient had coexisting risk factors for breast cancer. CONCLUSIONS Information framing had some effect on family physicians' intentions to prescribe HRT, but the effects were smaller than those previously reported, and they were modified by the presence of serious potential adverse treatment effects. PMID:10571703

Drug-related problems in hospitalized patients on polypharmacy: the influence of age and gender

PubMed Central

Koh, Yvonne; Kutty, Fatimah Bte Moideen; Li, Shu Chuen

2005-01-01

Background Drug-related problems (DRPs) have been shown to prevail in hospitalized patients, and polypharmacy and increasing age have been identified as two important risk factors. Objective We investigated the occurrence of DRPs and adverse drug reactions (ADRs) amongst hospitalized patients prescribed polypharmacy, and the association of advanced age and female gender. Method A retrospective cross-sectional study was performed in an acute-care hospital in Singapore. Only patients prescribed polypharmacy were included. Mann-Whitney test was used to test for significant difference between the age and gender of patients and their risk of acquiring DRPs. The relative risks of developing DRP and ADR for geriatric patients and female patients were estimated. Results Of 347 patients prescribed polypharmacy (43% female and 58.2% geriatrics), no statistical correlations were observed between age and gender with developing DRPs. An increased number of medications was associated with higher risk for patients with DRPs on admission (p = 0.001), but not for inpatients with DRPs (p = 0.119). Results from patients with ADRs showed that the relative risk (RR) of geriatrics prescribed polypharmacy and major polypharmacy (10 and more drugs) were 1.01 and 1.23, respectively. Female patients had a RR of 0.79 compared with male patients in developing ADRs. Conclusion Results showed that among patients with polypharmacy, age and gender may not be as important as number of drugs prescribed as predictors of experiencing a DRP. A similar trend was observed in the development of ADRs. PMID:18360542

Antibacterial Drugs Prescribed for Dogs and Cats in Sweden and Norway 1990–1998

PubMed Central

Odensvik, K; Grave, K; Greko, C

2001-01-01

The usage of veterinary antibacterial drugs in dogs and cats in Sweden and Norway for the period 1990–1998 was investigated by use of drug wholesalers' statistics. Additionally, usage of human antibacterial drugs in these species in Sweden was investigated by use of prescription data for the period 1996–1998. On average, more than 50% of the prescribed veterinary antibacterials in Sweden were beta-lactam antibiotics. In Norway, about 75% of the preparations prescribed for dogs and cats contained sulfonamides and trimethoprim. Furthermore, the prescription data from Sweden showed a reduced usage of human antibacterials prescribed for dogs and cats since the beginning of the 1980s. Approximately 20% of the prescribed packages for dogs in the years 1996–1998 were human approved drugs. The corresponding figure for cats was 13%. The differences between the countries in the choice of antibacterial drugs can be explained by differences in the availability of approved preparations during the study period. The consumption of veterinary antibacterials in dogs and cats in Sweden during the period was in the range of 3% to 8% of the total use of veterinary antibacterials. The corresponding figures in Norway were in the range of 3% to 7%. It is of vital importance to study usage patterns of antibacterial drugs in dogs and cats in surveillance and control of bacterial resistance, but also in discussions of therapeutic appropriateness. Therefore, further research is needed in this area. PMID:11455899

Optimal linear and nonlinear feature extraction based on the minimization of the increased risk of misclassification. [Bayes theorem - statistical analysis/data processing

NASA Technical Reports Server (NTRS)

Defigueiredo, R. J. P.

1974-01-01

General classes of nonlinear and linear transformations were investigated for the reduction of the dimensionality of the classification (feature) space so that, for a prescribed dimension m of this space, the increase of the misclassification risk is minimized.

An Analysis of Mathematics Course Sequences for Low Achieving Students at a Comprehensive Technical High School

ERIC Educational Resources Information Center

Edge, D. Michael

2011-01-01

This non-experimental study attempted to determine how the different prescribed mathematic tracks offered at a comprehensive technical high school influenced the mathematics performance of low-achieving students on standardized assessments of mathematics achievement. The goal was to provide an analysis of any statistically significant differences…

14 CFR 217.5 - Data collected (data elements).

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 4 2014-01-01 2014-01-01 false Data collected (data elements). 217.5..., CHARTER, AND NONSCHEDULED SERVICES § 217.5 Data collected (data elements). (a) Within each of the service classifications prescribed in § 217.4, data shall be reported in applicable traffic elements. (b) The statistical...

14 CFR 217.5 - Data collected (data elements).

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 4 2013-01-01 2013-01-01 false Data collected (data elements). 217.5..., CHARTER, AND NONSCHEDULED SERVICES § 217.5 Data collected (data elements). (a) Within each of the service classifications prescribed in § 217.4, data shall be reported in applicable traffic elements. (b) The statistical...

14 CFR 217.5 - Data collected (data elements).

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 4 2012-01-01 2012-01-01 false Data collected (data elements). 217.5..., CHARTER, AND NONSCHEDULED SERVICES § 217.5 Data collected (data elements). (a) Within each of the service classifications prescribed in § 217.4, data shall be reported in applicable traffic elements. (b) The statistical...

Assessing the Chances of Success: Naive Statistics versus Kind Experience

ERIC Educational Resources Information Center

Hogarth, Robin M.; Mukherjee, Kanchan; Soyer, Emre

2013-01-01

Additive integration of information is ubiquitous in judgment and has been shown to be effective even when multiplicative rules of probability theory are prescribed. We explore the generality of these findings in the context of estimating probabilities of success in contests. We first define a normative model of these probabilities that takes…

14 CFR 217.5 - Data collected (data elements).

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Data collected (data elements). 217.5..., CHARTER, AND NONSCHEDULED SERVICES § 217.5 Data collected (data elements). (a) Within each of the service classifications prescribed in § 217.4, data shall be reported in applicable traffic elements. (b) The statistical...

14 CFR 217.5 - Data collected (data elements).

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Data collected (data elements). 217.5..., CHARTER, AND NONSCHEDULED SERVICES § 217.5 Data collected (data elements). (a) Within each of the service classifications prescribed in § 217.4, data shall be reported in applicable traffic elements. (b) The statistical...

Swimming path statistics of an active Brownian particle with time-dependent self-propulsion

NASA Astrophysics Data System (ADS)

Babel, S.; ten Hagen, B.; Löwen, H.

2014-02-01

Typically, in the description of active Brownian particles, a constant effective propulsion force is assumed, which is then subjected to fluctuations in orientation and translation, leading to a persistent random walk with an enlarged long-time diffusion coefficient. Here, we generalize previous results for the swimming path statistics to a time-dependent, and thus in many situations more realistic, propulsion which is a prescribed input. We analytically calculate both the noise-free and the noise-averaged trajectories for time-periodic propulsion under the action of an additional torque. In the deterministic case, such an oscillatory microswimmer moves on closed paths that can be much more complicated than the commonly observed straight lines and circles. When exposed to random fluctuations, the mean trajectories turn out to be self-similar curves which bear the characteristics of their noise-free counterparts. Furthermore, we consider a propulsion force which scales in time t as ∝tα (with α = 0,1,2, …) and analyze the resulting superdiffusive behavior. Our predictions are verifiable for diffusiophoretic artificial microswimmers with prescribed propulsion protocols.

Do advertisements for antihypertensive drugs in Australia promote quality prescribing? A cross-sectional study.

PubMed

Montgomery, Brett D; Mansfield, Peter R; Spurling, Geoffrey K; Ward, Alison M

2008-05-20

Antihypertensive medications are widely prescribed by doctors and heavily promoted by the pharmaceutical industry. Despite strong evidence of the effectiveness and cost-effectiveness of thiazide diuretics, trends in both promotion and prescription of antihypertensive drugs favour newer, less cost-effective agents. Observational evidence shows correlations between exposure to pharmaceutical promotion and less ideal prescribing. Our study therefore aimed to determine whether print advertisements for antihypertensive medications promote quality prescribing in hypertension. We performed a cross-sectional study of 113 advertisements for antihypertensive drugs from 4 general practice-oriented Australian medical publications in 2004. Advertisements were evaluated using a quality checklist based on a review of hypertension management guidelines. Main outcome measures included: frequency with which antihypertensive classes were advertised, promotion of thiazide class drugs as first line agents, use of statistical claims in advertisements, mention of harms and prices in the advertisements, promotion of assessment and treatment of cardiovascular risk, promotion of lifestyle modification, and targeting of particular patient subgroups. Thiazides were the most frequently advertised drug class (48.7% of advertisements), but were largely promoted in combination preparations. The only thiazide advertised as a single agent was the most expensive, indapamide. No advertisement specifically promoted any thiazide as a better first-line drug. Statistics in the advertisements tended to be expressed in relative rather than absolute terms. Drug costs were often reported, but without cost comparisons between drugs. Adverse effects were usually reported but largely confined to the advertisements' small print. Other than mentioning drug interactions with alcohol and salt, no advertisements promoted lifestyle modification. Few advertisements (2.7%) promoted the assessment of cardiovascular risk. Print advertisements for antihypertensive medications in Australia provide some, but not all, of the key messages required for guideline-concordant care. These results have implications for the regulation of drug advertising and the continuing education of doctors.

What happens when GPs proactively prescribe NRT patches in a disadvantaged community.

PubMed

Copeland, L; Robertson, R; Elton, R

2005-05-01

The high prevalence of smoking in disadvantaged communities gives serious cause for concern in terms of adverse effects on health and social outcomes. In Scotland, smoking -related lung cancer rates are particularly high and compare less favourably with the rest of the U.K. and Europe. GPs are increasingly being recognised as having an important role in smoking cessation and are allowed to prescribe NRT to those on a low income. This study aimed to follow up a group patientsfrom a disadvantaged area who had been prescribed nicotine patches by their GP. An initial self-complete questionnaire gathered details on age, sex, motivation, marital status, employment history, contact with other smokers, concern about weight gain, and nicotine dependence. (Nicotine dependence was assessed by using the Fagerstrom Test). Follow up was carried out at three months after commencing NRT prescription. Data was also gathered from patient case notes as to whether the participant had a smoking-related diagnosis, periods of depression, drug and/or alcohol problems. Outcome was measured in terms of "smoke the same", "smoke less" and "stopped". The statistical methods used for testing each factor against smoking were Spearman rank correlation, chi-squared test for trend and Kruskal-Wallis test. Basic descriptive statistics were used to report general outcomes of the study. The study enrolled 120 patients but 19 were lost to follow up. Out of 101 who used their prescription, 35 were smoking the same, 46 were smoking less and 20 had stopped. The variables most strongly affecting outcome were age, with older smokers having more success (p < 0.001), and those who had a diagnosis of depression having a worse outcome in terms of smoking cessation (p < 0.05). This study's findings indicate that encouraging GPs to take a proactive approach in prescribing NRT is effective, even in an area of socio-economic deprivation, and particularly with older smokers.

Association between physicians’ interaction with pharmaceutical companies and their clinical practices: A systematic review and meta-analysis

PubMed Central

Al-Khaled, Lina; Kahale, Lara A.; Nas, Hala; El-Jardali, Fadi

2017-01-01

Background Pharmaceutical company representatives likely influence the prescribing habits and professional behaviors of physicians. The objective of this study was to systematically review the association between physicians’ interactions with pharmaceutical companies and their clinical practices. Methods We used the standard systematic review methodology. Observational and experimental study designs examining any type of targeted interaction between practicing physicians and pharmaceutical companies were eligible. The search strategy included a search of MEDLINE and EMBASE databases up to July 2016. Two reviewers selected studies, abstracted data, and assessed risk of bias in duplicate and independently. We assessed the quality of evidence using the GRADE approach. Results Twenty articles reporting on 19 studies met our inclusion criteria. All of these studies were conducted in high-income countries and examined different types of interactions, including detailing, industry-funded continuing medical education, and receiving free gifts. While all included studies assessed prescribing behaviors, four studies also assessed financial outcomes, one assessed physicians’ knowledge, and one assessed their beliefs. None of the studies assessed clinical outcomes. Out of the 19 studies, 15 found a consistent association between interactions promoting a medication, and inappropriately increased prescribing rates, lower prescribing quality, and/or increased prescribing costs. The remaining four studies found both associations and lack of significant associations for the different types of exposures and drugs examined in the studies. A meta-analysis of six of these studies found a statistically significant association between exposure and physicians’ prescribing behaviors (OR = 2.52; 95% CI 1.82–3.50). The quality of evidence was downgraded to moderate for risk of bias and inconsistency. Sensitivity analysis excluding studies at high risk of bias did not substantially change these results. A subgroup analysis did not find a difference by type of exposure. Conclusion There is moderate quality evidence that physicians’ interactions with pharmaceutical companies are associated with their prescribing patterns and quality. PMID:28406971

Enhancing HIV Pre-exposure, Prophylaxis Practices via an Educational Intervention.

PubMed

Newman, Rebecca; Katchi, Tasleem; Karass, Michael; Gennarelli, Melissa; Goutis, Jason; Kifayat, Alina; Solanki, Shantanu; Yandrapalli, Srikanth; Forman, Leanne; Nabors, Christopher

2018-04-20

Pre-exposure prophylaxis (PrEP) for HIV involves using antiretroviral drugs to prevent individuals at high risk from acquiring HIV infection. Most practicing primary care providers believe PrEP to be safe and effective, but less than half have prescribed or referred for PrEP. Attitudes and prescribing patterns among house officers have not been well described previously. Can an educational intervention enhance HIV PrEP practices among internal medicine house officers? This study relied on a pretest/posttest design. All categorical trainees at a medium-sized internal medicine program were offered a baseline survey to assess their knowledge on PrEP. This was followed by a PrEP-focused educational intervention and a postintervention survey. Likert scales captured perceptions regarding safety, effectiveness, barriers, factors that would promote PrEP use, potential side effects, impact on risk-taking behavior, and provider comfort level in assessing behavioral risks and in PrEP prescribing. Data were analyzed using descriptive statistics, Wilcoxon signed rank test, and the Kruskal-Wallis test. Significance was accepted for P < 0.05. Forty-eight (100%) trainees participated in the educational session, 45 (94%) in a preintervention survey, and 36 (75%) in a postintervention survey. Before PrEP training, 22% of respondents were unaware of PrEP, 78% believed PrEP was effective, 66% believed PrEP was safe, 62% had fair or poor awareness of side effects; 18% of residents had referred for or prescribed PrEP, and 31% believed they were likely to prescribe PrEP in the next 6 months. After the intervention, 94% of trainees believed PrEP was effective (P < 0.001), 92% believed PrEP was safe (P < 0.001), and two-thirds believed they were likely to prescribe PrEP in the next 6 months. Brief, focused training on HIV prevention promotes awareness, acceptance, and likelihood of prescribing PrEP by internal medicine trainees.

Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists

PubMed Central

Saha, Sajal K; Hawes, Lesley; Mazza, Danielle

2018-01-01

Introduction Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist–GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. Methods and analysis A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. Ethics and dissemination No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO registration number CRD42017078478. PMID:29654036

Method for Assessing Impacts of Global Sea Level Rise on Navigation Gate Operations

NASA Astrophysics Data System (ADS)

Obrien, P. S.; White, K. D.; Friedman, D.

2015-12-01

Coastal navigation infrastructure may be highly vulnerable to changing climate, including increasing sea levels and altered frequency and intensity of coastal storms. Future gate operations impacted by global sea level rise will pose unique challenges, especially for structures 50 years and older. Our approach is to estimate future changes in gate operational frequency based on a bootstrapping method to forecast future water levels. A case study will be presented to determine future changes in frequency of operations over the next 100 years. A statistical model in the R programming language was developed to apply future sea level rise projections using the three sea level rise scenarios prescribed by USACE Engineer Regulation ER 1100-2-8162. Information derived from the case study will help forecast changes in operational costs caused by increased gate operations and inform timing of decisions on adaptation measures.

How Physician Perspectives on E-Prescribing Evolve over Time

PubMed Central

Patel, Vaishali; Pfoh, Elizabeth R.; Kaushal, Rainu

2016-01-01

Summary Background Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians’ experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality. Objective Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing. Methods We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes. Results We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow. Conclusions Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency. PMID:27786335

International study on antidepressant prescription pattern at 20 teaching hospitals and major psychiatric institutions in East Asia: Analysis of 1898 cases from China, Japan, Korea, Singapore and Taiwan.

PubMed

Uchida, Naoki; Chong, Mian-Yoon; Tan, Chay Hoon; Nagai, Hiroshi; Tanaka, Mariko; Lee, Min-Soo; Fujii, Senta; Yang, Shu-Yu; Si, Tainmei; Sim, Kang; Wei, Hao; Ling, He Yan; Nishimura, Ryoji; Kawaguchi, Yoshichika; Edwards, Glen; Sartorius, Norman; Shinfuku, Naotaka

2007-10-01

The purpose of the present study was to review the prescription patterns of antidepressants in different countries in East Asia. The survey was conducted in China, Japan, Korea, Singapore and Taiwan from October 2003 to March 2004 using the unified research protocol and questionnaire. Twenty teaching hospitals and major psychiatric hospitals participated and a total of 1898 patients receiving antidepressants were analyzed. The survey provided a number of interesting characteristics on the prescription patterns of antidepressant in East Asia. Out of 56 antidepressants listed in the Anatomical Therapeutic Chemical Classification (ATC) index by the World Health Organization (WHO) Collaborating Center for Drug Statistics Methodology (Oslo), only 26 antidepressants were prescribed in participating countries in East Asia. On average 38.4% of prescriptions of antidepressants were for patients with diagnoses other than depressive disorders. The availability and commonly prescribed antidepressants varied greatly by country. The selective serotonin re-uptake inhibitors (SSRI) and other newer antidepressants were prescribed in approximately 77.0% of all cases. At the time of the survey, only two SSRI medications were available in Japan. However, five types of SSRI were available and were often prescribed in Korea.

Quetiapine for sleep in patients with dementia.

PubMed

Dolder, Christian R; McKinsey, Jonathan

2010-10-01

to examine the use of quetiapine for sleep in patients with dementia admitted to a geriatric psychiatry ward. retrospective cross-sectional study (January 2007 to December 2009). geriatric psychiatric unit located near a metropolitan city in North Carolina. all patients admitted with a diagnosis of dementia who were also receiving quetiapine were eligible. One hundred one patients met the criteria and were included in the study. none. descriptive statistics defining quetiapine prescribing. Based on a priori criteria, quetiapine was considered to be used for sleep if it were prescribed: 1) only at bedtime, as needed, for sleep, 2) once daily, only at bedtime, or 3) multiple times daily, but with at least 75% of the daily dose administered at bedtime. forty-three of the 101 patients included in the study were prescribed quetiapine, probably for sleep. Quetiapine, when used as a sedative-hypnotic, was generally employed at doses between 50 mg and 100 mg nightly. Several published studies report beneficial sleep-promoting effects of quetiapine and other atypical antipsychotics for primary and secondary sleep complaints; however, most of these trials involve young and middle-aged adults, have diagnostic variability, and are limited methodologically. quetiapine prescribed as a sedative-hypnotic in patients with dementia, while common, is understudied and not without risk.

Pharmacoepidemiology for nephrologists: do proton pump inhibitors cause chronic kidney disease?

PubMed Central

Tomlinson, Laurie A.; Fogarty, Damian G.; Douglas, Ian; Nitsch, Dorothea

2017-01-01

Abstract Pharmacoepidemiology studies are increasingly used for research into safe prescribing in chronic kidney disease (CKD). Typically, patients prescribed a drug are compared with patients who are not on the drug and outcomes are compared to draw conclusions about the drug effects. This review article aims to provide the reader with a framework to critically appraise such research. A key concern in pharmacoepidemiology studies is confounding, in that patients who have worse health status are prescribed more drugs or different agents and their worse outcomes are attributed to the drugs not the health status. It may be challenging to adjust for this using statistical methods unless a comparison group with a similar health status but who are prescribed a different (comparison) drug(s) is identified. Another challenge in pharmacoepidemiology is outcome misclassification, as people who are more ill engage more often with the health service, leading to earlier diagnosis in people who are frequent attenders. Finally, using replication cohorts with the same methodology in the same type of health system does not ensure that findings are more robust. We use two recent papers that investigated the association of proton pump inhibitor drugs with CKD as a device to review the main pitfalls of pharmacoepidemiology studies and how to attempt to mitigate against potential biases that can occur. PMID:28201528

The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature.

PubMed

Reisfield, Gary M; Wasan, Ajay D; Jamison, Robert N

2009-11-01

Cannabis is the most widely consumed illicit drug in the United States. Its use, particularly in early initiates, is associated with subsequent development of other drug and alcohol use disorders. The authors examined the prevalence of cannabis use and the association between cannabis use and aberrant opioid-related behaviors in patients prescribed chronic opioid therapy for persistent pain. PubMed was queried for studies of chronic opioid therapy in which aberrant opioid-related behaviors were quantitatively examined and in which cannabis use data (as determined by cannabinoid-positive urine drug tests) were extricable from that of other substances of abuse. The prevalence of cannabis use among patients prescribed chronic opioid therapy in these studies ranged from 6.2% to 39%, compared with 5.8% in the general United States population. Furthermore, cannabis use in chronic opioid patients shows statistically significant associations with present and future aberrant opioid-related behaviors. Cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse. Further research is necessary to clarify the strength and the nature of the association between cannabis use and opioid misuse, and to address additional questions about the consequences of cannabis use in the context of chronic opioid therapy.

A Cluster Randomised Controlled Trial of a Pharmacist-Led Collaborative Intervention to Improve Statin Prescribing and Attainment of Cholesterol Targets in Primary Care

PubMed Central

Lowrie, Richard; Lloyd, Suzanne M.; McConnachie, Alex; Morrison, Jill

2014-01-01

Background Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year. Methods We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years. Findings We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later. Interpretation Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population. Trial Registration International Standard Randomised Controlled Trials Register ISRCTN61233866 PMID:25405478

A cross-sectional survey of the access of older people in the Scottish Highlands to general medical practices, community pharmacies and prescription medicines.

PubMed

Rushworth, Gordon F; Cunningham, Scott; Pfleger, Sharon; Hall, Jenny; Stewart, Derek

2018-01-01

Access to medicines and healthcare is more problematic in remote and rural areas. To quantify issues of access to general practitioners (GPs), community pharmacies and prescribed medicines in older people resident in the Scottish Highlands. Anonymized questionnaires were mailed to a random sample of 2000 older people (≥60 years) resident in the Scottish Highlands. Questionnaire items were: access and convenience to GP and pharmacy services (10 items); prescribed medicines (13 items); attitudinal statements based on the Theoretical Domains Framework (12 items); quality of life (SF8, 8 items); and demographics (12 items). Results were analysed using descriptive, inferential and spatial statistics, and principal component analysis (PCA) of attitudinal items. With a response rate of 54.2%, the majority reported convenient access to GPs (89.1%) and community pharmacies (84.3%). Older age respondents (p < 0.0001) were more likely to state that their access to GP services was not convenient and those in rural areas to community pharmacies (p < 0.01). For access to prescribed medicines, those in poorer health (p < 0.001) and taking five or more regular prescribed medicines (p = 0.002) were more likely to state access not convenient. PCA identified three components of beliefs of capabilities, emotions and memory. Those with poorer health had more negative scores for all (p < 0.001). Those reporting issues of access to prescribed medicines had more negative scores for beliefs of capabilities (p < 0.001) while those of older age, living alone, and taking five or more regular prescribed medicines (all p < 0.001) had more negative scores for emotions. While the majority of respondents have convenient access to their GP practice, pharmacy and prescribed medicines, there is a need for further review of the pharmaceutical care of those of older age with poorer health, living alone in the more remote and rural areas and taking five or more prescribed medicines. Copyright © 2017 Elsevier Inc. All rights reserved.

Six-Year Follow-Up of Impact of Co-proxamol Withdrawal in England and Wales on Prescribing and Deaths: Time-Series Study

PubMed Central

Hawton, Keith; Bergen, Helen; Simkin, Sue; Wells, Claudia; Kapur, Navneet; Gunnell, David

2012-01-01

Background The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005–2010 compared with 1998–2004, including estimation of possible substitution effects by other analgesics. Methods and Findings We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005–2010 compared with 1998–2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of −21 deaths (95% CI −34 to −8) per quarter, equating to approximately 500 fewer suicide deaths (−61%) over the 6 years 2005–2010, and −25 deaths (95% CI −38 to −12) per quarter, equating to 600 fewer deaths (−62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed. Conclusions During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics. Please see later in the article for the Editors' Summary PMID:22589703

Effects of long-term prescribed burning on structure, composition, and timber quality of oak-hickory forests in the Missouri Ozarks

Treesearch

Benjamin O. Knapp; John M. Kabrick

2014-01-01

Prescribed fire is commonly being used as a management tool for restoring or maintaining woodlands in the Central Hardwood Forest region. Woodlands are characterized as having canopies that are more open than those of forests, with lower abundance of woody stems in the midstory and understory layers, and a dense, diverse ground flora that is dominated by herbaceous...

Effects of repeated prescribed fires on the structure, composition, and regeneration of mixed-oak forests in Ohio

Treesearch

Todd F. Hutchinson; Elaine Kennedy Sutherland; Daniel A. Yaussy

2005-01-01

This study quantifies prescribed fire effects at four sites in southern Ohio, from 1995 to 2002. Each site had three treatment units: an unburned control, a unit burned 2x (1996 and 1999), and a unit burned 4 x (1996-1999). Vegetation plots were stratified by an integrated moisture index (IMI) into xeric, intermediate, and mesic classes. Prior to treatments, oak (...

14 CFR 27.547 - Main rotor structure.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false Main rotor structure. 27.547 Section 27.547... structure. (a) Each main rotor assembly (including rotor hubs and blades) must be designed as prescribed in this section. (b) [Reserved] (c) The main rotor structure must be designed to withstand the following...

A Markov Chain Approach to Probabilistic Swarm Guidance

NASA Technical Reports Server (NTRS)

Acikmese, Behcet; Bayard, David S.

2012-01-01

This paper introduces a probabilistic guidance approach for the coordination of swarms of autonomous agents. The main idea is to drive the swarm to a prescribed density distribution in a prescribed region of the configuration space. In its simplest form, the probabilistic approach is completely decentralized and does not require communication or collabo- ration between agents. Agents make statistically independent probabilistic decisions based solely on their own state, that ultimately guides the swarm to the desired density distribution in the configuration space. In addition to being completely decentralized, the probabilistic guidance approach has a novel autonomous self-repair property: Once the desired swarm density distribution is attained, the agents automatically repair any damage to the distribution without collaborating and without any knowledge about the damage.

24 CFR 40.3 - Applicability.

Code of Federal Regulations, 2010 CFR

2010-04-01

... ACCESSIBILITY STANDARDS FOR DESIGN, CONSTRUCTION, AND ALTERATION OF PUBLICLY OWNED RESIDENTIAL STRUCTURES § 40.3 Applicability. (a) The standards prescribed in § 40.4 are applicable to residential structures designed after the effective date of this part. If the design of a structure commenced prior to that date, the...

Fatigue risks in the connections of sign support structures.

DOT National Transportation Integrated Search

2013-05-01

This research effort develops a reliability-based approach for prescribing inspection intervals for mast-arm sign support : structures corresponding to user-specified levels of fatigue-induced fracture risk. The resulting level of risk for a : partic...

Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia

PubMed Central

Podrasky, Joanna; McMonagle, Meghan A.; Raveendran, Janani; Bysshe, Tyler; Hogenmiller, Alycia

2017-01-01

Importance Gifts from pharmaceutical companies are believed to influence prescribing behavior, but few studies have addressed the association between industry gifts to physicians and drug costs, prescription volume, or preference for generic drugs. Even less research addresses the effect of gifts on the prescribing behavior of nurse practitioners (NPs), physician assistants (PAs), and podiatrists. Objective To analyze the association between gifts provided by pharmaceutical companies to individual prescribers in Washington DC and the number of prescriptions, cost of prescriptions, and proportion of branded prescriptions for each prescriber. Design Gifts data from the District of Columbia’s (DC) AccessRx program and the federal Center for Medicare and Medicaid Services (CMS) Open Payments program were analyzed with claims data from the CMS 2013 Medicare Provider Utilization and Payment Data. Setting Washington DC, 2013 Participants Physicians, nurse practitioners, physician assistants, podiatrists, and other licensed Medicare Part D prescribers who participated in Medicare Part D (a Federal prescription drug program that covers patients over age 65 or who are disabled). Exposure(s) Gifts to healthcare prescribers (including cash, meals, and ownership interests) from pharmaceutical companies. Main outcomes and measures Average number of Medicare Part D claims per prescriber, number of claims per patient, cost per claim, and proportion of branded claims. Results In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. In six specialties (General Internal Medicine, Family Medicine, Obstetrics/Gynecology, Urology, Ophthalmology, and Dermatology), gifts were associated with a significantly increased average cost of claims. For Internal Medicine, Family Medicine, and Ophthalmology, gifts were associated with more branded claims. Gift acceptance was associated with increased average cost per claim for PAs and NPs. Gift acceptance was also associated with higher proportion of branded claims for PAs but not NPs. Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups. All differences were statistically significant (p<0.05). Conclusions and relevance Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors. Our study confirms and expands on previous work showing that industry gifts are associated with more expensive prescriptions and more branded prescriptions. Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned. PMID:29069085

General Public Expectation from the Communication Process with their Healthcare Providers

PubMed Central

Hassali, MA; Shafie, AA; Khan, TM

2012-01-01

The current study aimed to explore the public views and expectation about a successful communication process between the healthcare providers/physicians and patients in Penang Island, Malaysia. A cross-sectional study was conducted in Penang Island using a 14-item questionnaire. Statistical Package for Social Sciences (SPSS) software version 15.0® were used to analyze the collected data. A nonparametric statistics was applied; the Chi-square test was applied to measure the association among the variables. P-values less than 0.05 were considered statistically significant. A total of N (500) respondents have shown willingness to participate in the study with a response rate of 83.3%. The majority 319 (63.9%) have disclosed to communicate with their healthcare providers in the Malay language and about 401 (80.4%) of the respondents were found satisfied with the information provided by the physician. It was a common expectation by the most of the sample to focus more on the patient history before prescribing any medicine. Moreover, about 60.0% of the respondents expected that the healthcare providers must show patience to the patient's queries. The level of satisfaction with the information shared by the healthcare providers was higher among the respondents with a higher education level. Furthermore, patients with higher level of education expect that physician shouldwell understand their views and medical history to prescribe a better therapeutic regimen. PMID:23112539

Diffusion of innovations: treatment of Alzheimer's disease in Germany.

PubMed

Ruof, Jörg; Mittendorf, Thomas; Pirk, Olaf; von der Schulenburg, J-Matthias Graf

2002-04-01

Systematic barriers seem to slow down the market penetration of innovative acethylcholinesterase (AChE) inhibitors in Alzheimer's disease. The goal of our study was to examine the diffusion of AChE inhibitors into the German market in more detail. On the basis of using the ongoing surveillance panel of the Institute of Medical Statistic (IMS) Health, the prescription patterns of 100 physicians (72 general practitioners, 28 neurologists) were examined. In addition, structured telephone interviews with the same 100 physicians were conducted. The interview included the assessment of a hypothetical treatment situation (i.e. physicians were asked what they would prescribe if a close relative of theirs had Alzheimer's disease) as well as qualitative items examining the physicians' attitudes towards AChE inhibitors and the perceived impact on drug budgets. As a major result, the analysis revealed that neurologists prescribed AChE inhibitors to 44.6% of their patients, while general practitioners only treated 9.0% of their patients with AChE inhibitors. The analysis of the qualitative items revealed positive attitudes regarding the safety and efficacy of AChE inhibitors, but negative attitudes regarding the budgetary limitations to prescribing these drugs. A correlation of r=0.21 (P<0.05) was found between the perceived impact on drug budgets and the adoption of AChE inhibitors and a correlation of r=0.32 (P<0.002) was seen between the physician's specialty and the adoption of AChE inhibitors. These data show that, while the AChE inhibitor adoption process has passed the early stages, various barriers slow down the final stages of AChE inhibitor adoption. The drug budget in particular seems to inhibit the adoption of the innovation by the majority of general practitioners. This leads to a more short-term cost control strategy instead of long-term disease management and cost saving approaches.

Population-Based Case–Control Study of Chinese Herbal Products Containing Aristolochic Acid and Urinary Tract Cancer Risk

PubMed Central

Lai, Ming-Nan; Chen, Pau-Chung; Chen, Ya-Yin

2010-01-01

Background Consumption of Chinese herbs that contain aristolochic acid (eg, Mu Tong) has been associated with an increased risk of urinary tract cancer. Methods We conducted a population-based case–control study in Taiwan to examine the association between prescribed Chinese herbal products that contain aristolochic acid and urinary tract cancer. All patients newly diagnosed with urinary tract cancer (case subjects) from January 1, 2001, to December 31, 2002, and a random sample of the entire insured population from January 1, 1997, to December 31, 2002 (control subjects), were selected from the National Health Insurance reimbursement database. Subjects who were ever prescribed more than 500 pills of nonsteroidal anti-inflammatory drugs and/or acetaminophen were excluded, leaving 4594 case patients and 174 701 control subjects in the final analysis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by using multivariable logistic regression models for the association between prescribed Chinese herbs containing aristolochic acid and the occurrence of urinary tract cancer. Models were adjusted for age, sex, residence in a township where black foot disease was endemic (an indicator of chronic arsenic exposure from drinking water [a risk factor for urinary tract cancer]), and history of chronic urinary tract infection. Statistical tests were two-sided. Results Having been prescribed more than 60 g of Mu Tong and an estimated consumption of more than 150 mg of aristolochic acid were independently associated with an increased risk for urinary tract cancer in multivariable analyses (Mu Tong: at 61–100 g, OR = 1.6, 95% CI = 1.3 to 2.1, and at >200 g, OR = 2.1, 95% CI = 1.3 to 3.4; aristolochic acid: at 151–250 mg, OR = 1.4, 95% CI = 1.1 to 1.8, and at >500 mg, OR = 2.0, 95% CI = 1.4 to 2.9). A statistically significant linear dose–response relationship was observed between the prescribed dose of Mu Tong or the estimated cumulative dose of aristolochic acid and the risk of urinary tract cancer (P < .001 for both). Conclusions Consumption of aristolochic acid–containing Chinese herbal products is associated with an increased risk of cancer of the urinary tract in a dose-dependent manner that is independent of arsenic exposure. PMID:20026811

Influence of provider and urgent care density across different socioeconomic strata on outpatient antibiotic prescribing in the USA

PubMed Central

Klein, Eili Y.; Makowsky, Michael; Orlando, Megan; Hatna, Erez; Braykov, Nikolay P.; Laxminarayan, Ramanan

2015-01-01

Objectives Despite a strong link between antibiotic use and resistance, and highly variable antibiotic consumption rates across the USA, drivers of differences in consumption rates are not fully understood. The objective of this study was to examine how provider density affects antibiotic prescribing rates across socioeconomic groups in the USA. Methods We aggregated data on all outpatient antibiotic prescriptions filled in retail pharmacies in the USA in 2000 and 2010 from IMS Health into 3436 geographically distinct hospital service areas and combined this with socioeconomic and structural factors that affect antibiotic prescribing from the US Census. We then used fixed-effect models to estimate the interaction between poverty and the number of physician offices per capita (i.e. physician density) and the presence of urgent care and retail clinics on antibiotic prescribing rates. Results We found large geographical variation in prescribing, driven in part by the number of physician offices per capita. For an increase of one standard deviation in the number of physician offices per capita there was a 25.9% increase in prescriptions per capita. However, the determinants of the prescription rate were dependent on socioeconomic conditions. In poorer areas, clinics substitute for traditional physician offices, reducing the impact of physician density. In wealthier areas, clinics increase the effect of physician density on the prescribing rate. Conclusions In areas with higher poverty rates, access to providers drives the prescribing rate. However, in wealthier areas, where access is less of a problem, a higher density of providers and clinics increases the prescribing rate, potentially due to competition. PMID:25604743

Influences on GPs' decision to prescribe new drugs-the importance of who says what.

PubMed

Prosser, Helen; Almond, Solomon; Walley, Tom

2003-02-01

The aim of this study was to understand the range of factors that influence GPs' uptake of new drugs A total of 107 GPs selected purposively from high, medium and low new drug prescribing practices in two health authorities in the north west of England were interviewed using the critical incident technique with semi-structured interviews. Interview topics included reasons for prescribing new drugs launched between January 1998 and May 1999; reasons for prescribing the new drug rather than alternatives; and sources of information used for each prescribed drug. Important biomedical influences were the failure of current therapy and adverse effect profile. More influential than these, however, was the pharmaceutical representative. Hospital consultants and observation of hospital prescribing was cited next most frequently. Patient request for a drug, and patient convenience and acceptability were also likely to influence new drug uptake. Written information was of limited importance except for local guidelines. GPs were largely reactive and opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by 'who says what', in particular the pharmaceutical industry, hospital consultants and patients. The decision to 'adopt' a new drug is clinched by subsequent personal clinical experience. Prescribing of new drugs is not simply related to biomedical evaluation and critical appraisal but, more importantly, to the mode of exposure to pharmacological information and social influences on decision making. Viewed within this broad context, prescribing variation becomes more understandable. Findings have implications for the implementation of evidence-based medicine, which requires a multifaceted approach.

Creating Realistic Data Sets with Specified Properties via Simulation

ERIC Educational Resources Information Center

Goldman, Robert N.; McKenzie, John D. Jr.

2009-01-01

We explain how to simulate both univariate and bivariate raw data sets having specified values for common summary statistics. The first example illustrates how to "construct" a data set having prescribed values for the mean and the standard deviation--for a one-sample t test with a specified outcome. The second shows how to create a bivariate data…

Potential fire behavior in California: an atlas and guide for forest and brushland managers

Treesearch

Bill C. Ryan

1984-01-01

Potential fire characteristics can be estimated as functions of weather, fuel, and terrain slope. Such information is needed by forest and other land managers--especially for anticipating fire suppression needs and planning prescribed burns. To provide this information, an Atlas has been developed for California. The Atlas includes statistical analyses of spread...

Observing fermionic statistics with photons in arbitrary processes

PubMed Central

Matthews, Jonathan C. F.; Poulios, Konstantinos; Meinecke, Jasmin D. A.; Politi, Alberto; Peruzzo, Alberto; Ismail, Nur; Wörhoff, Kerstin; Thompson, Mark G.; O'Brien, Jeremy L.

2013-01-01

Quantum mechanics defines two classes of particles-bosons and fermions-whose exchange statistics fundamentally dictate quantum dynamics. Here we develop a scheme that uses entanglement to directly observe the correlated detection statistics of any number of fermions in any physical process. This approach relies on sending each of the entangled particles through identical copies of the process and by controlling a single phase parameter in the entangled state, the correlated detection statistics can be continuously tuned between bosonic and fermionic statistics. We implement this scheme via two entangled photons shared across the polarisation modes of a single photonic chip to directly mimic the fermion, boson and intermediate behaviour of two-particles undergoing a continuous time quantum walk. The ability to simulate fermions with photons is likely to have applications for verifying boson scattering and for observing particle correlations in analogue simulation using any physical platform that can prepare the entangled state prescribed here. PMID:23531788

DRUGS System Improving the Effects of Clinical Pathways: A Systematic Study.

PubMed

Wang, Shan; Zhu, Xiaohe; Zhao, Xian; Lu, Yang; Yang, Zhifu; Qian, Xiaoliang; Li, Weiwei; Ma, Lixiazi; Guo, Huning; Wang, Jingwen; Wen, Aidong

2016-03-01

The aim of the study is to assess the feasibility of Drugs Rational Usage Guideline System (DRUGS)-supported clinical pathway (CP) for breast carcinoma, cataract, inguinal hernia and 2-diabetes mellitus whether the application of such a system could improve work efficiency, medical safety, and decrease hospital cost. Four kinds of diseases which included 1773 cases (where 901 cases using paper-based clinical pathways and 872 cases using DRUGS-supported clinical pathways) were selected and their demographic and clinical data were collected. The evaluation criteria were length of stay, preoperative length of stay, hospital cost, antibiotics prescribed during hospitalization, unscheduled surgery, complications and prognosis. The median total LOS was 1 to 3 days shorter in the DRUGS-supported CP group as compared to the Paper-based CP group for all types (p < 0.05). Totel hospital cost decreased significantly in the DRUGS-supported CP group than that in Paper-based CP group. About antibiotics prescribed during hospitalization, there were no statistically differences in the time of initial dose of antibiotic and the duration of administration except the choice of antibiotic categories. The proportion of DRUGS-supported clinical pathway conditions where a broad-spectrum antibiotic was prescribed decreased from 63.6 to 34.5 % (p < 0.01) in the Paper-based group. While after the intervention, the differences were statistically not significant in unscheduled surgery, complications and prognosis. In this study, DRUGS-supported clinical pathway for breast carcinoma, cataract, inguinal hernia, 2-diabetes mellitus was smoothly shifted from a paper-based to an electronic system, and confer benefits at the hospital level.

Optimizing prescribed fire allocation for managing fire risk in central Catalonia.

PubMed

Alcasena, Fermín J; Ager, Alan A; Salis, Michele; Day, Michelle A; Vega-Garcia, Cristina

2018-04-15

We used spatial optimization to allocate and prioritize prescribed fire treatments in the fire-prone Bages County, central Catalonia (northeastern Spain). The goal of this study was to identify suitable strategic locations on forest lands for fuel treatments in order to: 1) disrupt major fire movements, 2) reduce ember emissions, and 3) reduce the likelihood of large fires burning into residential communities. We first modeled fire spread, hazard and exposure metrics under historical extreme fire weather conditions, including node influence grid for surface fire pathways, crown fraction burned and fire transmission to residential structures. Then, we performed an optimization analysis on individual planning areas to identify production possibility frontiers for addressing fire exposure and explore alternative prescribed fire treatment configurations. The results revealed strong trade-offs among different fire exposure metrics, showed treatment mosaics that optimize the allocation of prescribed fire, and identified specific opportunities to achieve multiple objectives. Our methods can contribute to improving the efficiency of prescribed fire treatment investments and wildfire management programs aimed at creating fire resilient ecosystems, facilitating safe and efficient fire suppression, and safeguarding rural communities from catastrophic wildfires. The analysis framework can be used to optimally allocate prescribed fire in other fire-prone areas within the Mediterranean region and elsewhere. Copyright © 2017 Elsevier B.V. All rights reserved.

Long-term (13-year) effects of repeated prescribed fires on stand structure and tree regeneration in mixed-oak forests

Treesearch

Todd F. Hutchinson; Daniel A. Yaussy; Robert P. Long; Joanne Rebbeck; Elaine Kennedy. Sutherland

2012-01-01

The survival and growth of oak advance regeneration is often limited by shade-tolerant species that are abundant in the understory of oak stands. Evidence of historic burning has prompted the use of prescribed fire as a tool to improve the competitive status of oak regeneration in mature stands. A primary shortfall of fire effects research in oak forests has been a...

14 CFR 27.549 - Fuselage, landing gear, and rotor pylon structures.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Fuselage, landing gear, and rotor pylon structures. 27.549 Section 27.549 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... rotor pylon structure must be designed as prescribed in this section. Resultant rotor forces may be...

14 CFR 27.549 - Fuselage, landing gear, and rotor pylon structures.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 1 2012-01-01 2012-01-01 false Fuselage, landing gear, and rotor pylon structures. 27.549 Section 27.549 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... rotor pylon structure must be designed as prescribed in this section. Resultant rotor forces may be...

14 CFR 27.549 - Fuselage, landing gear, and rotor pylon structures.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 1 2011-01-01 2011-01-01 false Fuselage, landing gear, and rotor pylon structures. 27.549 Section 27.549 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... rotor pylon structure must be designed as prescribed in this section. Resultant rotor forces may be...

77 FR 37653 - Manufacturing Extension Partnership (MEP) Centers for Arizona, Maryland and Rhode Island...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

.... The management and operational structure of an MEP center is not prescribed, but should be based upon... Center? (1) Organizational Structure. Completeness and appropriateness of the organizational structure... primarily small- and medium-sized U.S. based manufacturing firms in its service region. Manufacturing...

Pharmacy and primary care perspectives on e-prescribing in a rural community: A focused ethnography.

PubMed

Kooienga, Sarah; Singh, Reshmi L

Electronic prescribing (ERx) is the ability for prescriber to send a digital prescription directly to a pharmacist through a dedicated secure network. A number of federally funded incentives such as the health information technology for economic and clinical health (HITECH) and Meaningful Use standards have led to ERx implementation. ERx is an integral part of primary care practice and today most community pharmacies are enabled to accept e-prescriptions. Little is known about the experience of rural pharmacists, primary care providers and patients regarding e-prescribing. This paper reports on the results of ERx from their perspectives. The findings are a portion of a larger qualitative descriptive study focused on the meaning of Meaningful Use in remote rural communities. One remote rural community in the Pacific Northwest was used for this research endeavor. Explore understandings of e-prescribing from both pharmacist and primary care provider perspective. Explore patients' understandings and experiences of e-prescribing. The conceptual model for this research was the Ecological Transactional Model. This model informed the research design, interview questions and analysis. A qualitative descriptive methodology - focused ethnography was used for this study. Six key informant interviews, 14 patient interviews and 15 hours of participant observation provided the data. Data analysis occurred collectively between a social pharmacy researcher, a primary care nurse practitioner-researcher and pharmacy graduate students. The research qualitatively identified contextual understandings and dimensions of ERx in this setting. Based on a focused ethnographic methodology, contextual understandings of rurality and role identity, both pharmacist and primary care provider, were explored. Perspectives on ERx of patients, clinic manager and RN staff were also elicited. Three dimensions of ERx were identified - technological, structural and communication. The structural, technological and communication dimensions are essential in understanding e-prescribing across settings and addressing digital divides in our health care system. Implications for interprofessional pharmacy education were addressed. Understanding the rural context and the need for role adaptability has implications for health care policy. Additional research is needed on the role of the rural pharmacist and how best to interact with primary care providers and patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Trimethoprim prescription and subsequent resistance in childhood urinary infection: multilevel modelling analysis

PubMed Central

Duffy, Mary A; Hernandez-Santiago, Virginia; Orange, Gillian; Davey, Peter G; Guthrie, Bruce

2013-01-01

Background Antibiotic resistance is a growing concern and antibiotic usage the main contributing factor, but there are few studies examining antibiotic use and resistance in children. Aim To investigate the association between previous trimethoprim prescribing and resistance in urinary Escherichia coli (E. coli) isolates in children. Design and setting Retrospective, population cohort study in Tayside, Scotland. Method Multilevel modelling of linked microbiology and dispensed prescribing data for 1373 ≤16-year-olds with E. coli urinary isolates in 2004–2009, examining the association between prior trimethoprim prescription and subsequent trimethoprim resistance in people with urinary E. coli isolates. Results Trimethoprim resistance was common (26.6%, 95% confidence interval [CI] = 24.6 to 28.6). Previous trimethoprim prescription was associated with subsequent culture of trimethoprim-resistant E. coli, with more recent prescription being more strongly associated with resistance. After adjusting for the number of previous E. coli isolates and sample year, trimethoprim prescribing in the previous 84 days remained significantly associated with culturing trimethoprim-resistant E. coli (adjusted OR 4.71, 95% CI = 1.83 to 12.16 for the previous 15–28 days versus never prescribed; adjusted OR 3.16, 95% CI = 1.63 to 6.13 for the previous 29–84 days); however, associations were not statistically significant for longer periods since prior exposure. Conclusion Trimethoprim prescription has implications for future resistance in individual children, as well as at population level. Clinicians must ensure appropriateness of treatment choice and duration, and alternative antibiotics should be considered for childhood urinary tract infections if trimethoprim has been prescribed in the preceding 3 months. PMID:23540479

Trimethoprim prescription and subsequent resistance in childhood urinary infection: multilevel modelling analysis.

PubMed

Duffy, Mary A; Hernandez-Santiago, Virginia; Orange, Gillian; Davey, Peter G; Guthrie, Bruce

2013-04-01

Antibiotic resistance is a growing concern and antibiotic usage the main contributing factor, but there are few studies examining antibiotic use and resistance in children. To investigate the association between previous trimethoprim prescribing and resistance in urinary Escherichia coli (E. coli) isolates in children. Retrospective, population cohort study in Tayside, Scotland. Multilevel modelling of linked microbiology and dispensed prescribing data for 1373 ≤16-year-olds with E. coli urinary isolates in 2004-2009, examining the association between prior trimethoprim prescription and subsequent trimethoprim resistance in people with urinary E. coli isolates. Trimethoprim resistance was common (26.6%, 95% confidence interval [CI] = 24.6 to 28.6). Previous trimethoprim prescription was associated with subsequent culture of trimethoprim-resistant E. coli, with more recent prescription being more strongly associated with resistance. After adjusting for the number of previous E. coli isolates and sample year, trimethoprim prescribing in the previous 84 days remained significantly associated with culturing trimethoprim-resistant E. coli (adjusted OR 4.71, 95% CI = 1.83 to 12.16 for the previous 15-28 days versus never prescribed; adjusted OR 3.16, 95% CI = 1.63 to 6.13 for the previous 29-84 days); however, associations were not statistically significant for longer periods since prior exposure. Trimethoprim prescription has implications for future resistance in individual children, as well as at population level. Clinicians must ensure appropriateness of treatment choice and duration, and alternative antibiotics should be considered for childhood urinary tract infections if trimethoprim has been prescribed in the preceding 3 months.

Accuracy of a cone beam computed tomography-guided surgical stent for orthodontic mini-implant placement.

PubMed

Yu, Jae-Jung; Kim, Gyu-Tae; Choi, Yong-Suk; Hwang, Eui-Hwan; Paek, Janghyun; Kim, Seong-Hun; Huang, John C

2012-03-01

To validate the accuracy of a cone-beam computed tomography (CBCT)-guided surgical stent for orthodontic mini-implant (OMI) placement by quantitatively evaluating the difference between CBCT-prescribed and actual position of mini-implants in preoperative and postoperative CBCT images. A surgical stent was fabricated using Teflon-Perfluoroalkoxy, which has appropriate biological x-ray attenuation properties. Polyvinylsiloxane impression material was used to secure the custom-made surgical stent onto swine mandibles. CBCT scanning was done with the stent in place to virtually plan mini-implants using a three-dimensional (3D) software program. An appropriate insertion point was determined using 3D reconstruction data, and the vertical and horizontal angulations were determined using four prescribed angles. A custom-designed surveyor was used to drill a guide hole within the surgical stent as prescribed on the CBCT images for insertion of 32 OMIs. The mandibles with a surgical stent in place were rescanned with CBCT to measure the deviations between the virtual planning data and surgical results. The difference between the prescribed and actual vertical angle was 1.01 ± 7.25, and the horizontal difference was 1.16 ± 6.08. The correlation coefficient confirms that there was no intrarater variability in either the horizontal (R  =  .97) or vertical (R  =  .74) vectors. The surgical stent in this study guides mini-implants to the prescribed position as planned in CBCT. Since the statistical difference was not significant, the surgical stent can be considered to be an accurate guide tool for mini-implant placement in clinical use.

Reduction in inappropriate prevention of urinary tract infections in long-term care facilities.

PubMed

Rummukainen, Maija-Liisa; Jakobsson, Aino; Matsinen, Maire; Järvenpää, Salme; Nissinen, Antti; Karppi, Pertti; Lyytikäinen, Outi

2012-10-01

Urinary tract infection (UTI) is the most common diagnosis made in prescribing antimicrobials in long-term care facilities (LTCF). The diagnostic criteria for UTI vary among institutions and prescribers. Our aim was to reduce the inappropriate use of antimicrobials in LTCFs. A team comprising infectious disease consultant, infection control nurse, and geriatrician visited all LTCFs for older persons (2,321 patients in 25 primary care hospitals and 39 nursing homes and dementia units) in the Central Finland Healthcare District (population 267,000) during 2004-2005. The site visits consisted of a structured interview concerning patients, ongoing systematic antimicrobials, and diagnostic practices for UTI. Following the visits, regional guidelines for prudent use of antimicrobials in LTCFs were published, and the use of antimicrobials was followed up by an annual questionnaire. The proportions of patients receiving antimicrobials in 2005, 2006, 2007, and 2008 were 19.9%, 16.9%, 16.2%, and 15.4%, respectively. Most of the antibiotics were used for UTI (range by year, 66.6%-81.1%). From 2005 through 2008, the proportion of patients on antibiotic prophylaxis for UTI decreased from 13% to 6%. The decrease was statistically significant in both types of settings. The visits and guidelines were associated with a reduction in the usage of antimicrobials. To sustain this, UTI surveillance and close collaboration between infection control experts and LTCFs are crucial. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

A Review of Alprazolam Use, Misuse, and Withdrawal

PubMed Central

Ait-Daoud, Nassima; Hamby, Allan Scott; Sharma, Sana; Blevins, Derek

2018-01-01

Alprazolam is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder. Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness, whereas many primary care physicians continue to prescribe it for longer periods than recommended. Clinical research data has not fully shed light on its “abuse liability,” yet it is one of the most frequently prescribed benzodiazepines. “Abuse liability” is the degree to which a psychoactive drug has properties that facilitate people misusing it, or becoming addicted to it, and is commonly used in the literature. We have replaced it in our manuscript with “misuse liability” as it reflects a more updated terminology consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In this paper, we have reviewed alprazolam’s indications for use, its effect on pregnant women, misuse liability, withdrawal syndrome, pharmacodynamic properties, and suggest better clinical prescription practice of alprazolam by presenting an indepth theory of its clinical effects with use and withdrawal. PMID:28777203

Personalized Medicine and Opioid Analgesic Prescribing for Chronic Pain: Opportunities and Challenges

PubMed Central

Bruehl, Stephen; Apkarian, A. Vania; Ballantyne, Jane C.; Berger, Ann; Borsook, David; Chen, Wen G.; Farrar, John T.; Haythornthwaite, Jennifer A.; Horn, Susan D.; Iadarola, Michael J.; Inturrisi, Charles E.; Lao, Lixing; Mackey, Sean; Mao, Jianren; Sawczuk, Andrea; Uhl, George R.; Witter, James; Woolf, Clifford J.; Zubieta, Jon-Kar; Lin, Yu

2013-01-01

Use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. There is currently no well-validated objective means of accurately identifying patients likely to experience good analgesia with low side effects and abuse risk prior to initiating opioid therapy. This paper discusses the concept of data-based personalized prescribing of opioid analgesics as a means to achieve this goal. Strengths, weaknesses, and potential synergism of traditional randomized placebo-controlled trial (RCT) and practice-based evidence (PBE) methodologies as means to acquire the clinical data necessary to develop validated personalized analgesic prescribing algorithms are overviewed. Several predictive factors that might be incorporated into such algorithms are briefly discussed, including genetic factors, differences in brain structure and function, differences in neurotransmitter pathways, and patient phenotypic variables such as negative affect, sex, and pain sensitivity. Currently available research is insufficient to inform development of quantitative analgesic prescribing algorithms. However, responder subtype analyses made practical by the large numbers of chronic pain patients in proposed collaborative PBE pain registries, in conjunction with follow-up validation RCTs, may eventually permit development of clinically useful analgesic prescribing algorithms. Perspective Current research is insufficient to base opioid analgesic prescribing on patient characteristics. Collaborative PBE studies in large, diverse pain patient samples in conjunction with follow-up RCTs may permit development of quantitative analgesic prescribing algorithms which could optimize opioid analgesic effectiveness, and mitigate risks of opioid-related abuse and mortality. PMID:23374939

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder.

PubMed

Chow, S-J; Sciberras, E; Gillam, L H; Green, J; Efron, D

2014-05-01

Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications. In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics. Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model. Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision. © 2013 John Wiley & Sons Ltd.

Factors influencing antibiotic-prescribing decisions among inpatient physicians: a qualitative investigation

PubMed Central

Livorsi, D; Comer, AR; Matthias, MS; Perencevich, EN; Bair, MJ

2016-01-01

Objective To understand the professional and psychosocial factors that influence physicians' antibiotic-prescribing habits in the inpatient setting. Design We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participants' responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis. Setting Two teaching hospitals in Indianapolis, IN Participants Thirty inpatient physicians (10 physicians-in-training, 20 supervising staff) Results Participants recognized that antibiotics are over-used, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Over-prescription was largely driven by anxiety about missing an infection while potential adverse effects of antibiotics did not strongly influence decision-making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues' antibiotic-prescribing decisions but frequently avoided providing direct feedback or critique, citing obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations. Conclusion There is a physician-based culture of prescribing antibiotics, which involves over-using antibiotics and not challenging colleagues' decisions. The potential adverse effects of antibiotics do not strongly influence decision-making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic-prescribing in the inpatient setting. PMID:26078017

Statistical significance test for transition matrices of atmospheric Markov chains

NASA Technical Reports Server (NTRS)

Vautard, Robert; Mo, Kingtse C.; Ghil, Michael

1990-01-01

Low-frequency variability of large-scale atmospheric dynamics can be represented schematically by a Markov chain of multiple flow regimes. This Markov chain contains useful information for the long-range forecaster, provided that the statistical significance of the associated transition matrix can be reliably tested. Monte Carlo simulation yields a very reliable significance test for the elements of this matrix. The results of this test agree with previously used empirical formulae when each cluster of maps identified as a distinct flow regime is sufficiently large and when they all contain a comparable number of maps. Monte Carlo simulation provides a more reliable way to test the statistical significance of transitions to and from small clusters. It can determine the most likely transitions, as well as the most unlikely ones, with a prescribed level of statistical significance.

Utilisation and Safety of Deferasirox: Results from an Observational Cohort Study in England.

PubMed

Osborne, Vicki; Davies, Miranda; Layton, Deborah; Shakir, Saad A W

2018-03-01

Deferasirox (EXJADE ® , Novartis, UK) is an oral iron-chelating agent primarily used to reduce chronic iron overload in patients receiving blood transfusions for various chronic anaemias and some non-transfusion dependant anaemias. The aim of this study was to examine the utilisation and safety of deferasirox used in general practice in England. A single exposure observational cohort study design was used. Patients were identified from dispensed prescriptions for deferasirox between September 2006 and September 2014. Outcome data were collected via postal questionnaires sent to prescribers ≥ 6 months after first dispensed prescription for an individual patient. Summary descriptive statistics were calculated. The evaluable cohort consisted of 122 patients, of which 41.8% were aged 2-17 years. Frequent reasons for prescribing were sickle cell anaemia (27/103 where specified, 26.2%) and beta thalassaemia (26, 25.2%). The majority of patients (43/51, 84.3%) were prescribed the licensed doses of 10 or 20 mg/kg/day at start. Prior measurements of serum creatinine were only reported for a small proportion this study (18/122, 14.8%). In total, 91 incident events were reported, including two of raised serum creatinine. These results show that deferasirox is largely being prescribed for its licensed indications in general practice in England and events reported were consistent with the known safety profile.

Efficacy of landscape scale woodland and savanna restoration at multiple spatial and temporal scales

USGS Publications Warehouse

Pittman, H. Tyler; Krementz, David G.

2016-01-01

The loss of historic ecosystem conditions has led forest managers to implement woodland and savanna ecosystem restoration on a landscape scale (≥10,000 ha) in the Ozark Plateau of Arkansas. Managers are attempting to restore and conserve these ecosystems through the reintroduction of disturbance, mainly short-rotation early-growing-season prescribed fire. Short-rotation early-growing season prescribed fire in the Ozarks typically occurs immediately before bud-break, through bud-break, and before leaf-out, and fire events occur on a three-to five-year interval. We examined short-rotation early-growing season prescribed fire as a restoration tool on vegetation characteristics. We collected vegetation measurements at 70 locations annually from 2011 to 2012 in and around the White Rock Ecosystem Restoration Area (WRERA), Ozark-St. Francis National Forest, Arkansas, and used generalized linear models to investigate the impact and efficacy of prescribed fire on vegetation structure. We found the number of large shrubs (>5 cm base diameter) decreased and small shrubs (<5 cm ground diameter) increased with prescribed fire severity. We found that horizontal understory cover from ground level to 1 m in height increased with time-since-prescribed-fire and woody ground cover decreased with the number of prescribed fire treatments. Using LANDFIRE datasets at the landscape scale, we found that since the initiation of a short-rotation early-growing season prescribed fire management regime, forest canopy cover has not reverted to levels characteristic of woodlands and savannas or reached restoration objectives over large areas. Without greater reductions in forest canopy cover and increases in forest-canopy cover heterogeneity, advanced regeneration will be limited in success, and woodland and savanna conditions will not return soon or to the extent desired.

What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study.

PubMed

Garada, Mona; McLachlan, Andrew J; Schiff, Gordon D; Lehnbom, Elin C

2017-11-15

Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels. Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing. Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Participants also believed it would improve consumers' medication understanding and adherence. Prescribers and pharmacists believed it could help reduce prescribing and dispensing errors by matching the drug/dosage to the correct indication. Prescribers refrained from documenting the indication to protect patients' privacy; however, most patients did not consider documenting the indication as a breach of privacy. Prescribers raised concerns about the extra time to include indications on prescriptions and best language to document indications, using plain language as opposed to medical terminology. All interviewed stakeholders identified numerous benefits of documenting the indication on prescriptions and dispensed medicines labels. Whether these potential benefits can be realized remains unknown and addressing prescribers' concern regarding the time involved in documenting the indication on prescriptions remains a challenge for vendors of electronic medication management systems.

Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study.

PubMed

McCrorie, Carolyn; Closs, S José; House, Allan; Petty, Duncan; Ziegler, Lucy; Glidewell, Liz; West, Robert; Foy, Robbie

2015-09-11

The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.

Mental models of adherence: parallels in perceptions, values, and expectations in adherence to prescribed home exercise programs and other personal regimens.

PubMed

Rizzo, Jon; Bell, Alexandra

2018-05-09

A mental model is the collection of an individual's perceptions, values, and expectations about a particular aspect of their life, which strongly influences behaviors. This study explored orthopedic outpatients mental models of adherence to prescribed home exercise programs and how they related to mental models of adherence to other types of personal regimens. The study followed an interpretive description qualitative design. Data were collected via two semi-structured interviews. Interview One focused on participants prior experiences adhering to personal regimens. Interview Two focused on experiences adhering to their current prescribed home exercise program. Data analysis followed a constant comparative method. Findings revealed similarity in perceptions, values, and expectations that informed individuals mental models of adherence to personal regimens and prescribed home exercise programs. Perceived realized results, expected results, perceived social supports, and value of convenience characterized mental models of adherence. Parallels between mental models of adherence for prescribed home exercise and other personal regimens suggest that patients adherence behavior to prescribed routines may be influenced by adherence experiences in other aspects of their lives. By gaining insight into patients adherence experiences, values, and expectations across life domains, clinicians may tailor supports that enhance home exercise adherence. Implications for Rehabilitation A mental model is the collection of an individual's perceptions, values, and expectations about a particular aspect of their life, which is based on prior experiences and strongly influences behaviors. This study demonstrated similarity in orthopedic outpatients mental models of adherence to prescribed home exercise programs and adherence to personal regimens in other aspects of their lives. Physical therapists should inquire about patients non-medical adherence experiences, as strategies patients customarily use to adhere to other activities may inform strategies to promote prescribed home exercise adherence.

Safer Prescribing and Care for the Elderly (SPACE): feasibility of audit and feedback plus practice mail-out to patients with high-risk prescribing.

PubMed

Wallis, Katharine; Tuckey, Rebecca

2017-06-01

INTRODUCTION High-risk prescribing in general practice is common and places patients at increased risk of adverse events. AIM The Safer Prescribing and Care for the Elderly (SPACE) intervention, comprising audit and feedback plus practice mail-out to patients with high-risk prescribing, was designed to promote medicines review and support safer prescribing. This study aims to test the SPACE intervention feasibility in general practice. METHODS This feasibility study involved an Auckland Primary Health Organisation (PHO), a clinical advisory pharmacist, two purposively sampled urban general practices, and seven GPs. The acceptability and utility of the SPACE intervention were assessed by semi- structured interviews involving study participants, including 11 patients with high-risk prescribing. Interviews were audio-recorded, transcribed verbatim and analysed using a general inductive approach to identify emergent themes. RESULTS The pharmacist said the SPACE intervention facilitated communication with GPs, and provided a platform for their clinical advisory role at no extra cost to the PHO. GPs said the feedback session with the pharmacist was educational but added to time pressures. GPs selected 29 patients for the mail-out. Some GPs were concerned the mail-out might upset patients, but patients said they felt cared for. Some patients intended to take the letter to their next appointment and discuss their medicines with their GP; others said there were already many things to discuss and not enough time. Some patients were confused by the medicines information brochure. DISCUSSION The SPACE intervention is feasible in general practice. The medicines information brochure needs simplification. Further research is needed to test the effect of SPACE on high-risk prescribing.

A comparison of effects from prescribed fires and wildfires managed for resource objectives in Sequoia and Kings Canyon National Parks

USGS Publications Warehouse

Nesmith, C.B.; Caprio, Anthony C.; Pfaff, Anne H.; McGinnis, Thomas W.; Keeley, Jon E.

2011-01-01

Current goals for prescription burning are focused on measures of fuel consumption and changes in forest density. These benchmarks, however, do not address the extent to which prescription burning meets perceived ecosystem needs of heterogeneity in burning, both for overstory trees and understory herbs and shrubs. There are still questions about how closely prescribed fires mimic these patterns compared to natural wildfires. This study compared burn patterns of prescribed fires and managed unplanned wildfires to understand how the differing burning regimes affect ecosystem properties. Measures of forest structure and fire severity were sampled in three recent prescribed fires and three wildfires managed for resource objectives in Sequoia and Kings Canyon National Parks. Fine scale patterns of fire severity and heterogeneity were compared between fire types using ground-based measures of fire effects on fuels and overstory and understory vegetation. Prescribed fires and wildfires managed for resource objectives displayed similar patterns of overstory and understory fire severity, heterogeneity, and seedling and sapling survival. Variation among plots within the same fire was always greater than between fire types. Prescribed fires can provide burned landscapes that approximate natural fires in many ways. It is recognized that constraints placed on when wildfires managed for resource objectives are allowed to burn freely may bias the range of conditions that might have been experienced under more natural conditions. Therefore they may not exactly mimic natural wildfires. Overall, the similarity in fire effects that we observed between prescribed fires and managed wildfires indicate that despite the restrictions that are often placed on prescribed fires, they appear to be creating post-fire conditions that approximate natural fires when assessed on a fine spatial scale.

Definitions and codes for seral status and structure of vegetation.

Treesearch

Frederick C. Hall; Larry Bryant; Rod Clausnitzer; Kathy Geier-Hayes; Robert Keane; Jane Kertis; Ayn Shlisky; Robert Steel

1995-01-01

Definitions and codes for identifying vegetation seral status and structure are desired for land management planning, appraising wildlife habitat, and prescribing vegetation treatment. Codes are only presented; they are not a system for determining seral status or stand structure. Terms defined are climax, potential natural community (PNC), succession, seral status,...

Design optimization of a prescribed vibration system using conjoint value analysis

NASA Astrophysics Data System (ADS)

Malinga, Bongani; Buckner, Gregory D.

2016-12-01

This article details a novel design optimization strategy for a prescribed vibration system (PVS) used to mechanically filter solids from fluids in oil and gas drilling operations. A dynamic model of the PVS is developed, and the effects of disturbance torques are detailed. This model is used to predict the effects of design parameters on system performance and efficiency, as quantified by system attributes. Conjoint value analysis, a statistical technique commonly used in marketing science, is utilized to incorporate designer preferences. This approach effectively quantifies and optimizes preference-based trade-offs in the design process. The effects of designer preferences on system performance and efficiency are simulated. This novel optimization strategy yields improvements in all system attributes across all simulated vibration profiles, and is applicable to other industrial electromechanical systems.

Strategies for preventing invasive plant outbreaks after prescribed fire in ponderosa pine forest

USGS Publications Warehouse

Symstad, Amy J.; Newton, Wesley E.; Swanson, Daniel J.

2014-01-01

Land managers use prescribed fire to return a vital process to fire-adapted ecosystems, restore forest structure from a state altered by long-term fire suppression, and reduce wildfire intensity. However, fire often produces favorable conditions for invasive plant species, particularly if it is intense enough to reveal bare mineral soil and open previously closed canopies. Understanding the environmental or fire characteristics that explain post-fire invasive plant abundance would aid managers in efficiently finding and quickly responding to fire-caused infestations. To that end, we used an information-theoretic model-selection approach to assess the relative importance of abiotic environmental characteristics (topoedaphic position, distance from roads), pre-and post-fire biotic environmental characteristics (forest structure, understory vegetation, fuel load), and prescribed fire severity (measured in four different ways) in explaining invasive plant cover in ponderosa pine forest in South Dakota’s Black Hills. Environmental characteristics (distance from roads and post-fire forest structure) alone provided the most explanation of variation (26%) in post-fire cover of Verbascum thapsus (common mullein), but a combination of surface fire severity and environmental characteristics (pre-fire forest structure and distance from roads) explained 36–39% of the variation in post-fire cover of Cirsium arvense (Canada thistle) and all invasives together. For four species and all invasives together, their pre-fire cover explained more variation (26–82%) in post-fire cover than environmental and fire characteristics did, suggesting one strategy for reducing post-fire invasive outbreaks may be to find and control invasives before the fire. Finding them may be difficult, however, since pre-fire environmental characteristics explained only 20% of variation in pre-fire total invasive cover, and less for individual species. Thus, moderating fire intensity or targeting areas of high severity for post-fire invasive control may be the most efficient means for reducing the chances of post-fire invasive plant outbreaks when conducting prescribed fires in this region.

Bird functional diversity decreases with time since disturbance: Does patchy prescribed fire enhance ecosystem function?.

PubMed

Sitters, Holly; Di Stefano, Julian; Christie, Fiona; Swan, Matthew; York, Alan

2016-01-01

Animal species diversity is often associated with time since disturbance, but the effects of disturbances such as fire on functional diversity are unknown. Functional diversity measures the range, abundance, and distribution of trait values in a community, and links changes in species composition with the consequences for ecosystem function. Improved understanding of the relationship between time since fire (TSF) and functional diversity is critical given that the frequency of both prescribed fire and wildfire is expected to increase. To address this knowledge gap, we examined responses of avian functional diversity to TSF and two direct measures of environmental heterogeneity, plant diversity, and structural heterogeneity. We surveyed birds across a 70-year chronosequence spanning four vegetation types in southeast Australia. Six bird functional traits were used to derive four functional diversity indices (richness, evenness, divergence, and dispersion) and the effects of TSF, plant diversity and structural heterogeneity on species richness and the functional diversity indices were examined using mixed models. We used a regression tree method to identify traits associated with species more common in young vegetation. Functional richness and dispersion were negatively associated with TSF in all vegetation types, suggesting that recent prescribed fire generates heterogeneous vegetation and provides greater opportunities for resource partitioning. Species richness was not significantly associated with TSF, and is probably an unreliable surrogate for functional diversity in fire-prone systems. A positive, relationship between functional evenness and structural heterogeneity was comnon to all vegetation types, suggesting that fine-scale (tens of meters) structural variation can enhance ecosystem function. Species more common in young vegetation were primarily linked by their specialist diets, indicating that ecosystem services such as seed dispersal and insect control are enhanced in more recently burnt vegetation. We suggest that patchy prescribed fire sustains functional diversity, and that controlled use of patchy fire to break up large expanses of mature vegetation will enhance ecosystem function.

Specialty training and the personal use of benzodiazepines by physicians affect their proneness to prescribe tranquilizers.

PubMed

Linden, M; Gothe, H

1998-03-01

The decision on how to treat a patient does not depend on clinical matters or illness characteristics alone, but also on patient, physician and setting variables such as personality, training, or reimbursement. No research has yet been carried out to answer the question whether personal experience with medications also influences prescribing behavior. In this study, 124 physicians stratified according to specialty (neuropsychiatrists vs. general practitioners), type of institution (private practice vs. hospital), years of professional experience (young vs. old), and region (rural vs. urban) participated in a structured interview to evaluate their proneness to prescribe benzodiazepines for sleep disorders as well as their personal experience in taking benzodiazepines for their own sleep problems. Both specialty and personal experience were significantly related to proneness to prescribe. Other variables tested (region, institution, age, gender) did not help to explain the variance in benzodiazepine prescribing practice. Thus physician variables and, importantly, their own personal experience in taking the medication significantly influence treatment choice. Rational medical decision making and treatment guidelines must therefore take into account medical knowledge as well as knowledge of personal treatment preferences and professional biases.

Current Trend of Antimicrobial Prescription for Oral Implant Surgery Among Dentists in India.

PubMed

Datta, Rahul; Grewal, Yasmin; Batth, J S; Singh, Amandeep

2014-12-01

The aim of our study was to evaluate antimicrobial prescription behaviour amongst dentists performing oral implant surgery in India. Dentists performing oral implant surgery from different parts of India were personally approached during various national events such as conferences and academic meetings and information regarding their prescription habits for antimicrobial agents in routine oral implant surgery was collected using a structured questionnaire. Out of a total sample of 332 dentists, 85.5 % prescribed 17 different groups or combinations of antibiotics routinely for oral implant surgery in the normal healthy patient. Majority preferred the peri-operative protocol of drug therapy (72.2 %) with variable and prolonged duration of therapy after surgery, ranging from 3 to 10 days. An antimicrobial mouthwash was routinely prescribed by all the doctors (14.5 %) not in favour of prescribing antimicrobials in a normal healthy patient. Our findings suggest that there is a trend of antimicrobial agent misuse by dentists performing oral implant surgery in India, both in terms of drugs used and the protocols prescribed. The majority of these dentists prescribed a variety of antimicrobial agents for prolonged durations routinely even in the normal, healthy patients.

Barriers to physician adherence to nonsteroidal anti-inflammatory drug guidelines: a qualitative study.

PubMed

Cavazos, J M; Naik, A D; Woofter, A; Abraham, N S

2008-09-15

Despite wide availability of physician guidelines for safer use of nonsteroidal anti-inflammatory drugs (NSAIDs) and widespread use of these drugs in the US, NSAID prescribing guidelines have been only modestly effective. To identify and describe comprehensively barriers to provider adherence to NSAID prescribing guidelines. We conducted interviews with 25 physicians, seeking to identify the major influences explaining physician non-adherence to guidelines. Interviews were standardized and structured probes were used for clarification and detail. All interviews were audio-taped and transcribed. Three independent investigators analysed the transcripts, using the constant-comparative method of qualitative analysis. Our analysis identified six dominant physician barriers explaining non-adherence to established NSAID prescribing guidelines. These included (i) lack of familiarity with guidelines, (ii) perceived limited validity of guidelines, (iii) limited applicability of guidelines among specific patients, (iv) clinical inertia, (v) influences of prior anecdotal experiences and (vi) medical heuristics. A heterogeneous set of influences are barriers to physician adherence to NSAID prescribing guidelines. Suggested measures for improving guideline-concordant prescribing should focus on measures to improve physician education and confidence in guidelines, implementation of physician/pharmacist co-management strategies and expansion of guideline scope.

A survey of the views and capabilities of community pharmacists in Western Australia regarding the rescheduling of selected oral antibiotics in a framework of pharmacist prescribing

PubMed Central

Sinkala, Fatima; Parsons, Richard; Sunderland, Bruce; Hoti, Kreshnik

2018-01-01

Background Antibiotic misuse in the community contributes to antimicrobial resistance. One way to address this may be by better utilizing community pharmacists’ skills in antibiotic prescribing. The aims of this study were to examine the level of support for “down-scheduling” selected antibiotics and to evaluate factors determining the appropriateness of community pharmacist prescribing for a limited range of infections, including their decision to refer to a doctor. Methods Self-administered questionnaires, including graded case vignette scenarios simulating real practice, were sent to Western Australian community pharmacists. In addition to descriptive statistics and chi-square testing, a General Estimating Equation (GEE) was used to identify factors associated with appropriateness of therapy and the decision to refer, for each of the seven vignettes. Results Of the 240 pharmacists surveyed, 90 (37.5%) responded, yielding 630 responses to seven different case vignettes. There was more than 60% respondent support for expanded prescribing (rescheduling) of commonly prescribed antibiotics. Overall 426/630 (67.6%) chose to treat the patient while the remaining 204/630 (32.4%) referred the patient to a doctor. Of those electing to treat, 380/426 (89.2%) opted to use oral antibiotics, with 293/380 (77.2%) treating with an appropriate selection and regimen. The GEE model indicated that pharmacists were more likely to prescribe inappropriately for conditions such as otitis media (p = 0.0060) and urinary tract infection in pregnancy (p < 0.0001) compared to more complex conditions. Over 80% of all pharmacists would refer the patient to a doctor following no improvement within 3 days, or within 24 h in the case of community acquired pneumonia. It was more common for younger pharmacists to refer the patient to a doctor (p = 0.0165). Discussion This study adds further insight into community pharmacy/pharmacist characteristics associated with appropriateness of oral antibiotic selection and the decision to refer to doctors. These findings require consideration in designing pharmacist over-the-counter prescribing models for oral antibiotics. PMID:29761047

A survey of the views and capabilities of community pharmacists in Western Australia regarding the rescheduling of selected oral antibiotics in a framework of pharmacist prescribing.

PubMed

Sinkala, Fatima; Parsons, Richard; Sunderland, Bruce; Hoti, Kreshnik; Czarniak, Petra

2018-01-01

Antibiotic misuse in the community contributes to antimicrobial resistance. One way to address this may be by better utilizing community pharmacists' skills in antibiotic prescribing. The aims of this study were to examine the level of support for "down-scheduling" selected antibiotics and to evaluate factors determining the appropriateness of community pharmacist prescribing for a limited range of infections, including their decision to refer to a doctor. Self-administered questionnaires, including graded case vignette scenarios simulating real practice, were sent to Western Australian community pharmacists. In addition to descriptive statistics and chi-square testing, a General Estimating Equation (GEE) was used to identify factors associated with appropriateness of therapy and the decision to refer, for each of the seven vignettes. Of the 240 pharmacists surveyed, 90 (37.5%) responded, yielding 630 responses to seven different case vignettes. There was more than 60% respondent support for expanded prescribing (rescheduling) of commonly prescribed antibiotics. Overall 426/630 (67.6%) chose to treat the patient while the remaining 204/630 (32.4%) referred the patient to a doctor. Of those electing to treat, 380/426 (89.2%) opted to use oral antibiotics, with 293/380 (77.2%) treating with an appropriate selection and regimen. The GEE model indicated that pharmacists were more likely to prescribe inappropriately for conditions such as otitis media ( p = 0.0060) and urinary tract infection in pregnancy ( p  < 0.0001) compared to more complex conditions. Over 80% of all pharmacists would refer the patient to a doctor following no improvement within 3 days, or within 24 h in the case of community acquired pneumonia. It was more common for younger pharmacists to refer the patient to a doctor ( p  = 0.0165). This study adds further insight into community pharmacy/pharmacist characteristics associated with appropriateness of oral antibiotic selection and the decision to refer to doctors. These findings require consideration in designing pharmacist over-the-counter prescribing models for oral antibiotics.

The effect of prescribed burning on plant rarity in a temperate forest.

PubMed

Patykowski, John; Holland, Greg J; Dell, Matt; Wevill, Tricia; Callister, Kate; Bennett, Andrew F; Gibson, Maria

2018-02-01

Rare species can play important functional roles, but human-induced changes to disturbance regimes, such as fire, can inadvertently affect these species. We examined the influence of prescribed burns on the recruitment and diversity of plant species within a temperate forest in southeastern Australia, with a focus on species that were rare prior to burning. Floristic composition was compared among plots in landscapes before and after treatment with prescribed burns differing in the extent of area burnt and season of burn (before-after, control-impact design). Floristic surveys were conducted before burns, at the end of a decade of drought, and 3 years postburn. We quantified the effect of prescribed burns on species grouped by their frequency within the landscape before burning (common, less common, and rare) and their life-form attributes (woody perennials, perennial herbs or geophytes, and annual herbs). Burn treatment influenced the response of rare species. In spring-burn plots, the recruitment of rare annual herbs was promoted, differentiating this treatment from both autumn-burn and unburnt plots. In autumn-burn plots, richness of rare species increased across all life-form groups, although composition remained statistically similar to control plots. Richness of rare woody perennials increased in control plots. For all other life-form and frequency groups, the floristic composition of landscapes changed between survey years, but there was no effect of burn treatment, suggesting a likely effect of rainfall on species recruitment. A prescribed burn can increase the occurrence of rare species in a landscape, but burn characteristics can affect the promotion of different life-form groups and thus affect functional diversity. Drought-breaking rain likely had an overarching effect on floristic composition during our study, highlighting that weather can play a greater role in influencing recruitment and diversity in plant communities than a prescribed burn.

A pilot qualitative study to explore stakeholder opinions regarding prescribing quality indicators

PubMed Central

2012-01-01

Background Information on prescribing quality of diabetes care is required by health care providers, insurance companies, policy makers, and the public. Knowledge regarding the opinions and preferences of all involved parties regarding prescribing quality information is important for effective use of prescribing quality indicators. Methods Between June and December 2009 we conducted semi structured interviews with 16 key-informants representing eight different organizations in the Netherlands involved in healthcare quality measurement and improvement. The interview guide included topics on participants’ opinions and preferences regarding existing types of prescribing quality indicators in relation to their aim of using quality information. Content analysis methods were used to process the resulting transcripts following the framework of predetermined themes. Results Findings from this qualitative study of stakeholder preferences showed that indicators focusing on undertreatment are found important by all participants. Furthermore, health care providers and policy makers valued prescribing safety indicators, insurance companies prioritized indicators focusing on prescribing costs, and patients’ organization representatives valued indicators focusing on interpersonal side of prescribing. Representatives of all stakeholders preferred positive formulation of the indicators to motivate health care providers to participate in health improvement programs. A composite score was found to be most useful by all participants as a starting point of prescribing quality assessment. Lack of information on reasons for deviating from guidelines recommendations appeared to be the most important barrier for using prescribing quality indicators. According to the health care providers, there are many legitimate reasons for not prescribing the recommended treatment and these reasons are not always taken into account by external evaluators. The latter may cause mistrust of health care providers towards external stakeholders and limit the use of PQI in external quality improvement programs. Conclusion Prescribing quality indicators are considered to be an important tool for assessing quality of provided diabetes care by all participants, although the preferences for specific types of indicators may differ by stakeholder depending on their user aim. Introduction of information systems to register the reasons for deviating from the recommended drug treatment may contribute to a more widespread use of PQI for assessment of provided health care quality to diabetic patents. This study identified the potential preferences regarding quality indicators for diabetes care, and this could be used for development of questionnaires to conduct a survey among a larger group of participants. PMID:22769967

Hypertensive patients' preferences for complementary and alternative medicine and the influence of these preferences on the adherence to prescribed medication.

PubMed

Lee, Khuan; Mokhtar, Halimatun Halaliah; Krauss, Steven Eric; Ong, Beng Kok

2014-05-01

This study aimed to understand hypertensive patients' perceptions of and adherence to prescribed medication. A qualitative research study based on 23 purposely selected participants from a community health clinic in Malaysia. The participants underwent in-depth semi-structured interviews, and the data were analyzed using qualitative content analysis method. The participants were presented with six types of perceptions of medication. The majority of the participants had negative perceptions of Western medicine (WM), self-adjusted their prescribed medication with complementary and alternative medicine (CAM) and concealed their self-adjusting habits from their doctors. Participants who thought positively of WM took their prescribed medication regularly. Most of the participants perceived the nature of WM as not being curative because of its side effects. Patients have the right to choose their preferred medication when they understand their illness. Local health care systems should provide patients with alternative health services that suit their requests. Copyright © 2014 Elsevier Ltd. All rights reserved.

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross‐sectional Survey Among 185 Medical Schools in 27 Countries

PubMed Central

Tichelaar, J; Okorie, M; Bissell, L; Christiaens, T; Likic, R; Mačìulaitis, R; Costa, J; Sanz, EJ; Tamba, BI; Maxwell, SR; Richir, MC; van Agtmael, MA

2017-01-01

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real‐life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU. PMID:28295236

Improved prescribed performance control for air-breathing hypersonic vehicles with unknown deadzone input nonlinearity.

PubMed

Wang, Yingyang; Hu, Jianbo

2018-05-19

An improved prescribed performance controller is proposed for the longitudinal model of an air-breathing hypersonic vehicle (AHV) subject to uncertain dynamics and input nonlinearity. Different from the traditional non-affine model requiring non-affine functions to be differentiable, this paper utilizes a semi-decomposed non-affine model with non-affine functions being locally semi-bounded and possibly in-differentiable. A new error transformation combined with novel prescribed performance functions is proposed to bypass complex deductions caused by conventional error constraint approaches and circumvent high frequency chattering in control inputs. On the basis of backstepping technique, the improved prescribed performance controller with low structural and computational complexity is designed. The methodology guarantees the altitude and velocity tracking error within transient and steady state performance envelopes and presents excellent robustness against uncertain dynamics and deadzone input nonlinearity. Simulation results demonstrate the efficacy of the proposed method. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

Parametric design of pressure-relieving foot orthosis using statistics-based finite element method.

PubMed

Cheung, Jason Tak-Man; Zhang, Ming

2008-04-01

Custom-molded foot orthoses are frequently prescribed in routine clinical practice to prevent or treat plantar ulcers in diabetes by reducing the peak plantar pressure. However, the design and fabrication of foot orthosis vary among clinical practitioners and manufacturers. Moreover, little information about the parametric effect of different combinations of design factors is available. As an alternative to the experimental approach, therefore, computational models of the foot and footwear can provide efficient evaluations of different combinations of structural and material design factors on plantar pressure distribution. In this study, a combined finite element and Taguchi method was used to identify the sensitivity of five design factors (arch type, insole and midsole thickness, insole and midsole stiffness) of foot orthosis on peak plantar pressure relief. From the FE predictions, the custom-molded shape was found to be the most important design factor in reducing peak plantar pressure. Besides the use of an arch-conforming foot orthosis, the insole stiffness was found to be the second most important factor for peak pressure reduction. Other design factors, such as insole thickness, midsole stiffness and midsole thickness, contributed to less important roles in peak pressure reduction in the given order. The statistics-based FE method was found to be an effective approach in evaluating and optimizing the design of foot orthosis.

Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics.

PubMed

Williams, Emily C; Achtmeyer, Carol E; Young, Jessica P; Berger, Douglas; Curran, Geoffrey; Bradley, Katharine A; Richards, Julie; Siegel, Michael B; Ludman, Evette J; Lapham, Gwen T; Forehand, Mark; Harris, Alex H S

2018-03-01

Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely. This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications. Qualitative, interview-based study. Twenty-four providers from five VA PC clinics. Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review. Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have. We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

14 CFR 25.561 - General.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS: TRANSPORT CATEGORY AIRPLANES Structure Emergency Landing Conditions § 25.561 General. (a) The airplane, although it may be damaged in emergency landing conditions on land or water, must be designed as prescribed in this section to protect each occupant under those conditions. (b) The structure must be...

The Hospitalist Perspective on Opioid Prescribing: A Qualitative Analysis

PubMed Central

Calcaterra, Susan L.; Drabkin, Anne D.; Leslie, Sarah E.; Doyle, Reina; Koester, Stephen; Frank, Joseph W.; Reich, Jennifer A.; Binswanger, Ingrid A.

2016-01-01

Background Pain is a frequent symptom among patients in the hospital. Pain management is a key quality indicator for hospitals and hospitalists are encouraged to frequently assess and treat pain. Optimal opioid prescribing, described as safe, patient-centered and informed opioid prescribing, may be at odds with the priorities of current hospital care, which focuses on patient-reported pain control rather than the potential long-term consequences of opioid use. Objective We aimed to understand physicians’ attitudes, beliefs and practices towards opioid prescribing during hospitalization and discharge. Design In-depth, semi-structured interviews Setting Two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital located in Denver, Colorado or Charleston, South Carolina. Participants Hospitalists (N=25) Measurements We systematically analyzed transcribed interviews and identified emerging themes using a team-based mixed inductive and deductive approach. Results Although hospitalists felt confident in their ability to control acute pain using opioid medications, they perceived limited success and satisfaction when managing acute exacerbations of chronic pain with opioids. Hospitalists recounted negative sentinel events which altered opioid prescribing practices in both the hospital setting and at the time of hospital discharge. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions. At times, this left them feeling conflicted about how this practice could impact the patient over the long term. Conclusions Strategies to provide adequate pain relief to hospitalized patients, which allow hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed. PMID:27157317

Structured Medication Review to Improve Pharmacotherapy in People with Intellectual Disability and Behavioural Problems.

PubMed

Scheifes, Arlette; Egberts, Toine C G; Stolker, Joost Jan; Nijman, Henk L I; Heerdink, Eibert R

2016-07-01

Polypharmacy and chronic drug use are common in people with intellectual disability and behavioural problems, although evidence of effectiveness and safety in this population is lacking. This study examined the effects of a structured medication review and aimed to improve pharmacotherapy in inpatients with intellectual disability. In a treatment facility for people with mild to borderline intellectual disability and severe behavioural problems, a structured medication review was performed. Prevalence and type of drug-related problems (DRPs) and of the recommended and executed actions were calculated. In a total of 55 patients with intellectual disability and behavioural problems, 284 medications were prescribed, in which a DRP was seen in 106 (34%). No indication/unclear indication was the most prevalent DRP (70). Almost 60% of the recommended actions were also executed. This high prevalence of DRPs is worrying. The structured medication review is a valuable instrument to optimize pharmacotherapy and to support psychiatrists in adequate prescribing of both psychotropic and somatic drugs. © 2015 John Wiley & Sons Ltd.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care.

PubMed

Weeks, Greg; George, Johnson; Maclure, Katie; Stewart, Derek

2016-11-22

A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

Patient satisfaction with the clinical pharmacist and prescribers during hepatitis C virus management.

PubMed

Martin, M T; Faber, D M

2016-12-01

Clinical pharmacists play an important role in the management of patients undergoing hepatitis C virus (HCV) treatment. No satisfaction surveys have been published on clinical pharmacist interventions in HCV management. The objective was to evaluate patient satisfaction with clinical pharmacist and prescriber services in the HCV patient population at an urban academic hepatology clinic. An anonymous patient satisfaction survey was offered to patients who were initiating or receiving HCV treatment under the care of a clinical pharmacist. Survey items assessed demographics and satisfaction with HCV care. Satisfaction was assessed with 17 or 20 Likert-scale questions (1 = poor, 2 = fair, 3 = okay, 4 = good, 5 = great) and two or three open-ended questions. Survey results were analysed via comparative and descriptive statistics. A qualitative content analysis was used for the open-ended survey questions. Sixty-four patients completed 77 (24 pharmacist and 53 prescriber) patient satisfaction surveys. The mean age was 53 (±9·72) years. Patients reported high levels of satisfaction with the pharmacist and prescribers. All 24 (100%) patients ranked overall satisfaction with services provided by pharmacists as 'great', and 36 (69%) of 52 patients ranked overall satisfaction with services provided by prescribers as 'great'. Patients supported the inclusion of a clinical pharmacist on health care teams for other disease states. Patients reported high levels of satisfaction with the clinical pharmacist involved in HCV treatment management at an urban academic medical centre. Clinical pharmacist services were highly valued and recommended by the patients surveyed. The survey was able to identify areas in need of improvement in the clinic. Clinical pharmacists play an important role in the treatment and management of HCV. This survey may serve as a model for assessment of satisfaction in other pharmacist-run clinic settings. © 2016 John Wiley & Sons Ltd.

An investigation of the concomitant use of angiotensin-converting enzyme inhibitors, non-steroidal anti-inflammatory drugs and diuretics.

PubMed

Bucsa, C; Moga, D C; Farcas, A; Mogosan, C; Dumitrascu, D L

2015-08-01

To determine in retrospective data the prevalence at hospital discharge of co-prescribing angiotensin-converting enzyme inhibitors (ACE-I) and non-steroidal anti-inflammatory drugs (NSAIDs) and ACE-I/NSAIDs and diuretics and to identify factors associated with the co-prescription. Secondary, we evaluated the extent of serum creatinine and potassium monitoring in patients treated with ACE-I and these associations and determined the prevalence of values above the upper normal limit (UNL) in monitored patients. Hospitalized patients with ACE-I in their therapy at discharge were included in 3 groups as follows: ACE-I, DT (double therapy with ACE-I and NSAIDs) and TT (triple therapy with ACE-I, NSAIDs and diuretics) groups. We evaluated differences on demographic characteristics, co-morbidities, medications, laboratory monitoring and quantified the patients with serum creatinine and potassium levels above the UNL using descriptive statistics. Logistic regression analysis with backward elimination was performed to identify significant predictors of combination therapy. Of 9960 admitted patients, 1214 were prescribed ACE-I, 40 were prescribed ACE-I/NSAIDs and 22 were prescribed ACE-I/NSAIDs/diuretics (3.13% and 1.72%, respectively, of the patients prescribed with ACE-I). Serum creatinine and potassium were monitored for the great majority of patients from all groups. The highest percentage of hyperkalemia was found in the DT group (10% of the patients) and of serum creatinine above UNL in the TT group (45.45%). The logistic regression final model showed that younger patients and monitoring for potassium were significantly associated with combination therapy. The prevalence of patients receiving DT/TT was relatively low and their monitoring during hospitalization was high. Factors associated with the combinations were younger patients and patients not tested for serum potassium.

Nurse prescribers' interactions with and perceptions of pharmaceutical sales representatives.

PubMed

Clauson, Kevin A; Khanfar, Nile M; Polen, Hyla H; Gibson, Florencetta

2009-01-01

The aim of our study was to investigate the perceptions of pharmaceutical sales representatives by nurse prescribers. Nurses with advanced training have earned prescriptive authority in North America, Europe and other parts of the world. These nurses are being increasingly targeted by pharmaceutical sales representatives. There is a paucity of data regarding nurses' perceptions of pharmaceutical sales representatives. Survey. A convenience sample of nurse prescribers was recruited to complete an Internet questionnaire about their interactions with and perceptions of sales representatives. The data were collected over one month ending in January 2007. There were 39 survey items ranging from perception-based items assessed by Likert-type scale to open-ended queries. Descriptive statistics were used to summarise the results. Ninety-two nurses completed this survey, which demonstrated good internal consistency yielding a Cronbach's alpha coefficient of 0.83. Positive perceptions of pharmaceutical representatives included: explaining their products clearly (80.4%) and knowledge about their medications (88.0%). Negative aspects included: lack of consideration of nurses' time (50%) and failure to equally discuss medication strengths and weaknesses (21.8%). Perhaps the most alarming finding was that 35.9% of respondents indicated that sales representatives suggested paybacks for promoting their drugs. Nurses with prescriptive authority generally perceive interactions with pharmaceutical sales representatives as positive. However, they also have concerns about the nature and methods of some of their activities. Nations that have nurses with prescribing authority can benefit from observing both the mis-steps and the positive inroads that have already been made by the profession in the USA and other countries. Appropriate use of pharmaceutical sales representatives' services may enhance the ability of nurse prescribers to deliver optimal nursing care. Methods, such as counter-detailing may be necessary to maintain an evidence-based approach as the controlling factor.

Prescribing joint co-ordinates during model preparation to improve inverse kinematic estimates of elbow joint angles.

PubMed

Wells, D J M; Alderson, J A; Dunne, J; Elliott, B C; Donnelly, C J

2017-01-25

To appropriately use inverse kinematic (IK) modelling for the assessment of human motion, a musculoskeletal model must be prepared 1) to match participant segment lengths (scaling) and 2) to align the model׳s virtual markers positions with known, experimentally derived kinematic marker positions (marker registration). The purpose of this study was to investigate whether prescribing joint co-ordinates during the marker registration process (within the modelling framework OpenSim) will improve IK derived elbow kinematics during an overhead sporting task. To test this, the upper limb kinematics of eight cricket bowlers were recorded during two testing sessions, with a different tester each session. The bowling trials were IK modelled twice: once with an upper limb musculoskeletal model prepared with prescribed participant specific co-ordinates during marker registration - MR PC - and once with the same model prepared without prescribed co-ordinates - MR; and by an established direct kinematic (DK) upper limb model. Whilst both skeletal model preparations had strong inter-tester repeatability (MR: Statistical Parametric Mapping (SPM1D)=0% different; MR PC : SPM1D=0% different), when compared with DK model elbow FE waveform estimates, IK estimates using the MR PC model (RMSD=5.2±2.0°, SPM1D=68% different) were in closer agreement than the estimates from the MR model (RMSD=44.5±18.5°, SPM1D=100% different). Results show that prescribing participant specific joint co-ordinates during the marker registration phase of model preparation increases the accuracy and repeatability of IK solutions when modelling overhead sporting tasks in OpenSim. Copyright © 2016 Elsevier Ltd. All rights reserved.

Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013.

PubMed

Sharma, Prateek; Finley, Rita; Weese, Scott; Glass-Kaastra, Shiona; McIsaac, Warren

2017-01-01

Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007-2013. Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices.

Acid suppressants for managing gastro-oesophageal reflux and gastro-oesophageal reflux disease in infants: a national survey.

PubMed

Bell, Jane C; Schneuer, Francisco J; Harrison, Christopher; Trevena, Lyndal; Hiscock, Harriet; Elshaug, Adam G; Nassar, Natasha

2018-02-22

To evaluate the diagnosis and management of reflux and gastro-oesophageal reflux disease (GORD) in infants aged <1 year presenting to general practitioners (GPs). A nationally representative, prospective, cross-sectional survey of GP activity in Australia, 2006-2016 (Bettering the Evaluation And Care of Health Study). Annually, a random sample of around 1000 GPs recorded details for 100 consecutive visits with consenting, unidentified patients. Diagnoses of reflux and GORD and their management including prescribing of acid-suppressant medicines (proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs)) and counselling, advice or education. Of all infants' visits, 512 (2.7%) included a diagnosis of reflux (n=413, 2.2%) or GORD (n=99, 0.5%). From 2006 to 2016, diagnostic rates decreased for reflux and increased for GORD. Prescribing of acid suppressants occurred in 43.6% visits for reflux and 48.5% visits for GORD, similar to rates of counselling, advice or education (reflux: 38.5%, GORD: 43.4% of visits). Prescribing of PPIs increased (statistically significant only for visits for reflux), while prescribing of H2RAs decreased. Overprescribing of acid suppressants to infants may be occurring. In infants, acid-suppressant medicines are no better than placebo and may have significant negative side effects; however, guidelines are inconsistent. Clear, concise and consistent guidance is needed. GPs and parents need to understand what is normal and limitations of medical therapy. We need a greater understanding of the influences on GP prescribing practices, of parents' knowledge and attitudes and of the pressures on parents of infants with these conditions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Primary care clinicians' experiences prescribing HIV pre-exposure prophylaxis at a specialized community health centre in Boston: lessons from early adopters.

PubMed

Krakower, Douglas S; Maloney, Kevin M; Grasso, Chris; Melbourne, Katherine; Mayer, Kenneth H

2016-01-01

An estimated 1.2 million Americans have indications for using antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. For many of these at-risk individuals, the best opportunity to learn about and receive PrEP will be during routine visits to their generalist primary care clinicians. However, few generalist clinicians have prescribed PrEP, primarily because of practical concerns about providing PrEP in primary care settings. The experiences of specialized primary care clinicians who have prescribed PrEP can inform the feasibility of PrEP provision by generalists. During January to February 2015, 35 primary care clinicians at a community health centre in Boston that specializes in the care of sexual and gender minorities completed anonymous surveys about their experiences and practices with PrEP provision. Responses were analyzed with descriptive statistics. Thirty-two clinicians (response rate=91%) completed the surveys. Nearly all clinicians (97%) had prescribed PrEP (median 20 patients, interquartile range 11-33). Most clinicians reported testing and risk-reduction counselling practices concordant with U.S. Centers for Disease Control and Prevention guidelines for PrEP. Clinicians indicated that patients using PrEP experienced medication toxicities infrequently and generally reported high adherence. However, some clinicians' practices differed from guideline recommendations, and some clinicians observed patients with increased risk behaviours. Most clinicians (79%) rated PrEP provision as easy to accomplish, and 97% considered themselves likely to prescribe PrEP in the future. In a primary care clinic with specialized expertise in HIV prevention, clinicians perceived that PrEP provision to large numbers of patients was safe, feasible and potentially effective. Efforts to engage generalist primary care clinicians in PrEP provision could facilitate scale-up of this efficacious intervention.

Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013

PubMed Central

Weese, Scott; Glass-Kaastra, Shiona; McIsaac, Warren

2017-01-01

Introduction Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007–2013. Materials/Methods Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. Results Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). Conclusion This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices. PMID:28750020

Demographic and Prescribing Patterns of Chinese Herbal Products for Individualized Therapy for Ischemic Heart Disease in Taiwan: Population-Based Study

PubMed Central

Hu, Wen-Long; Chen, Hsuan-Ju; Li, Tsai-Chung; Tsai, Pei-Yuan; Chen, Hsin-Ping; Huang, Meng-Hsuan; Su, Fang-Yen

2015-01-01

Objective Combinations of Chinese herbal products (CHPs) are widely used for ischemic heart disease (IHD) in Taiwan. We analyzed the usage and frequency of CHPs prescribed for patients with IHD. Methods A nationwide population-based cross-sectional study was conducted, 53531 patients from a random sample of one million in the National Health Insurance Research Database (NHIRD) from 2000 to 2010 were enrolled. Descriptive statistics, the multiple logistic regression method and Poisson regression analysis were employed to estimate the adjusted odds ratios (aORs) and adjusted risk ratios (aRRs) for utilization of CHPs. Results The mean age of traditional Chinese medicine (TCM) nonusers was significantly higher than that of TCM users. Zhi-Gan-Cao-Tang (24.85%) was the most commonly prescribed formula CHPs, followed by Xue-Fu-Zhu-Yu-Tang (16.53%) and Sheng-Mai-San (16.00%). The most commonly prescribed single CHPs were Dan Shen (29.30%), Yu Jin (7.44%), and Ge Gen (6.03%). After multivariate adjustment, patients with IHD younger than 29 years had 2.62 times higher odds to use TCM than those 60 years or older. Residents living in Central Taiwan, having hyperlipidemia or cardiac dysrhythmias also have higher odds to use TCM. On the contrary, those who were males, who had diabetes mellitus (DM), hypertension, stroke, myocardial infarction (MI) were less likely to use TCM. Conclusions Zhi-Gan-Cao-Tang and Dan Shen are the most commonly prescribed CHPs for IHD in Taiwan. Our results should be taken into account by physicians when devising individualized therapy for IHD. Further large-scale, randomized clinical trials are warranted in order to determine the effectiveness and safety of these herbal medicines. PMID:26322893

Diabetes self management: are Cuban Americans receiving quality health care?

PubMed

Huffman, Fatma G; Vaccaro, Joan A; Nath, Subrata; Zarini, Gustavo G

2009-01-01

We investigated the relationship among factors predicting inadequate glucose control among 182 Cuban-American adults (Females = 110, Males = 72) with type 2 diabetes mellitus (CAA). Cross-sectional study of CAA from a randomized mailing list in two counties of South Florida. Fasted blood parameters and anthropometric measures were collected during the study. BMI was calculated (kg/m2). Characteristics and diabetes care of CAA were self-reported Participants were screened by trained interviewers for heritage and diabetes status (inclusion criteria: self-reported having type 2 diabetes; age > or = 35 years, male and female; not pregnant or lactating; no thyroid disorders; no major psychiatric disorders). Participants signed informed consent form. Statistical analyses used SPSS and included descriptive statistic, multiple logistic and ordinal logistic regression models, where all CI 95%. Eighty-eight percent of CAA had BMI of > or = 25 kg/m2. Only 54% reported having a diet prescribed/told to schedule meals. We found CAA told to schedule meals were 3.62 more likely to plan meals (1.81, 7.26), p < 0.001) and given a prescribed diet, controlling for age, corresponded with following a meal plan OR 4.43 (2.52, 7.79, p < 0.001). The overall relationship for HbA1c < 8.5 to following a meal plan was OR 9.34 (2.84, 30.7. p < 0.001). The advantage of having a medical professional prescribe a diet seems to be an important environmental support factor in this sample's diabetes care, since obesity rates are well above the national average. Nearly half CAA are not given dietary guidance, yet our results indicate CAA may improve glycemic control by receiving dietary instructions.

Evaluation of the quality of life of patients with diabetes mellitus treated with conventional or analogue insulins.

PubMed

Machado-Alba, Jorge Enrique; Medina-Morales, Diego Alejandro; Echeverri-Cataño, Luis Felipe

2016-06-01

The results of two scales that measure quality of life of patients with diabetes mellitus treated with conventional or analogue insulin were evaluated and compared. Descriptive, observational, cross-sectional study, conducted in the cities of Pereira and Manizales, Colombia, in a care facility between 1 August 2013 and 30 March 2014. A total of 238 patients diagnosed with diabetes mellitus type 1 or type 2 who had been undergoing treatment with conventional or analogue insulin for at least 6months. Comparison of the results of the Diabetes 39 (specific) and European Quality of Life-5 Dimensions (EQ-5D) (generic) tools it was performed. Comparisons between the results of the two instruments were performed. Tests for parametric and non-parametric distribution (Pearson's correlation coefficient, Mann-Whitney U test, Student's t-test and Wilcoxon test) were used. The mean age was 57.7±16.6years. Conventional insulin was prescribed to 69.6% of patients, and analogue insulin was prescribed to 30.4% of patients. Diabetes-39 (D-39) showed 24.7% of subjects with a high quality of life. No statistically significant differences were found when comparing patients prescribed conventional or analogue insulin (p=0.35; 95% confidence interval [CI]: 0.375-1.419). In the EQ-5D survey, 45.7% claimed to have a high quality of life, without statistically significant differences between groups (p=0.56; 95%CI: 0.676-2.047). No differences between patients receiving conventional insulin versus analogue insulin were detected in terms of quality of life. The group aged over 60years requires special attention to improve their quality of life, and programs should focus on those individuals. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

A coupled CFD and wake model simulation of helicopter rotor in hover

NASA Astrophysics Data System (ADS)

Zhao, Qinghe; Li, Xiaodong

2018-03-01

The helicopter rotor wake plays a dominant role since it affects the flow field structure. It is very difficult to predict accurately of the flow-field. The numerical dissipation is so excessive that it eliminates the vortex structure. A hybrid method of CFD and prescribed wake model was constructed by applying the prescribed wake model as much as possible. The wake vortices were described as a single blade tip vortex in this study. The coupling model is used to simulate the flow field. Both non-lifting and lifting cases have been calculated with subcritical and supercritical tip Mach numbers. Surface pressure distributions are presented and compared with experimental data. The calculated results agree well with the experimental data.

Finite element analysis and optimization of composite structures

NASA Technical Reports Server (NTRS)

Thomsen, Jan

1990-01-01

Linearly elastic fiber reinforced composite discs and laminates in plane stress with variable local orientation and concentration of one or two fiber fields embedded in the matrix material, are considered. The thicknesses and the domain of the discs or laminates are assumed to be given, together with prescribed boundary conditions and in-plane loading along the edge. The problem under study consists in determining throughout the structural domain the optimum orientations and concentrations of the fiber fields in such a way as to maximize the integral stiffness of the composite disc or laminate under the seven loading. Minimization of the integral stiffness can also be performed. The optimization is performed subject to a prescribed bound on the total cost or weight of the composite that for given unit cost factors or specific weights determines the amounts of fiber and matrix materials in the structure. Examples are presented.

Vegetation response to stand structure and prescribed fire in an interior ponderosa pine ecosystem

Treesearch

Jianwei Zhang; Martin W. Ritchie; William W. Oliver

2008-01-01

A large-scale interior ponderosa pine (Pinus ponderosa Dougl. ex P. & C. Laws.) study was conducted at the Blacks Mountain Experimental Forest in northeastern California. The primary purpose of the study was to determine the influence of structural diversity on the dynamics of interior pine forests at the landscape scale. High structural...

26 CFR 1.170-2 - Charitable deductions by individuals; limitations (before amendment by Tax Reform Act of 1969).

Code of Federal Regulations, 2010 CFR

2010-04-01

... from a representative number of persons; that pursuant to its organizational structure and method of... created organization, that its organizational structure and method of operation are such as to require... charter relating to its organizational structure and prescribed methods of operation, P is a “publicly...

Simulation of spatially evolving turbulence and the applicability of Taylor's hypothesis in compressible flow

NASA Technical Reports Server (NTRS)

Lee, Sangsan; Lele, Sanjiva K.; Moin, Parviz

1992-01-01

For the numerical simulation of inhomogeneous turbulent flows, a method is developed for generating stochastic inflow boundary conditions with a prescribed power spectrum. Turbulence statistics from spatial simulations using this method with a low fluctuation Mach number are in excellent agreement with the experimental data, which validates the procedure. Turbulence statistics from spatial simulations are also compared to those from temporal simulations using Taylor's hypothesis. Statistics such as turbulence intensity, vorticity, and velocity derivative skewness compare favorably with the temporal simulation. However, the statistics of dilatation show a significant departure from those obtained in the temporal simulation. To directly check the applicability of Taylor's hypothesis, space-time correlations of fluctuations in velocity, vorticity, and dilatation are investigated. Convection velocities based on vorticity and velocity fluctuations are computed as functions of the spatial and temporal separations. The profile of the space-time correlation of dilatation fluctuations is explained via a wave propagation model.

Statistical mechanics and combinatorics of some discrete lattice models

NASA Astrophysics Data System (ADS)

Ayyer, Arvind

Many problems in statistical physics involve enumeration of certain objects. In this thesis, we apply ideas from combinatorics and statistical physics to understand three different lattice models. (I) We investigate the structure of the nonequilibrium stationary state (NESS) of a system of first and second class particles on L sites of a one-dimensional lattice in contact with first class particle reservoirs at the boundary sites and second class particles constrained to lie the system. The internal dynamics are described by the usual totally asymmetric exclusion process (TASEP) with second class particles. We show in a conceptually simple way how pinned and unpinned (fat) shocks determine the general structure of the phase diagram. We also point out some unexpected features in the microscopic structure of the NESS both for finite L and in the limit L → infinity. In the latter case the local distribution of second class particles is given by an equilibrium pressure ensemble with a pair potential between neighboring particles which grows logarithmically with distance. (II) We model a long linear polymer constrained between two plates as a walk on a two-dimensional lattice constrained to lie between two lines, x = y and x = y+w, which interacts with these lines via contact parameters s and t. The atomic steps of the walk can be taken to be from an arbitrary but fixed set S with the only condition being that the first coordinate of every element in S is strictly positive. For any such S and any w, we prescribe general algorithms (fully implemented in Maple) for the automated calculation of several mathematical and physical quantities of interest. (III) Ferrers (or Young) diagrams are very classical objects in representation theory, whose half-perimeter generating function of Ferrers diagrams is a straightforward rational function. We construct two new classes of Ferrers diagrams, which we call wicketed and gated Ferrers diagrams, which have internal voids in the shape of Ferrers diagrams, and calculate their half-perimeter generating functions, one of which is closely related to the generating function of the Catalan numbers, using a more abstract version of the usual transfer matrix method.

Using Parameter Constraints to Choose State Structures in Cost-Effectiveness Modelling.

PubMed

Thom, Howard; Jackson, Chris; Welton, Nicky; Sharples, Linda

2017-09-01

This article addresses the choice of state structure in a cost-effectiveness multi-state model. Key model outputs, such as treatment recommendations and prioritisation of future research, may be sensitive to state structure choice. For example, it may be uncertain whether to consider similar disease severities or similar clinical events as the same state or as separate states. Standard statistical methods for comparing models require a common reference dataset but merging states in a model aggregates the data, rendering these methods invalid. We propose a method that involves re-expressing a model with merged states as a model on the larger state space in which particular transition probabilities, costs and utilities are constrained to be equal between states. This produces a model that gives identical estimates of cost effectiveness to the model with merged states, while leaving the data unchanged. The comparison of state structures can be achieved by comparing maximised likelihoods or information criteria between constrained and unconstrained models. We can thus test whether the costs and/or health consequences for a patient in two states are the same, and hence if the states can be merged. We note that different structures can be used for rates, costs and utilities, as appropriate. We illustrate our method with applications to two recent models evaluating the cost effectiveness of prescribing anti-depressant medications by depression severity and the cost effectiveness of diagnostic tests for coronary artery disease. State structures in cost-effectiveness models can be compared using standard methods to compare constrained and unconstrained models.

Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population.

PubMed

Bradford, Ashley C; Bradford, W David; Abraham, Amanda; Bagwell Adams, Grace

2018-05-01

Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320% between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws (MCLs). The association between MCLs and opioid prescriptions is not well understood. To examine the association between prescribing patterns for opioids in Medicare Part D and the implementation of state MCLs. Longitudinal analysis of the daily doses of opioids filled in Medicare Part D for all opioids as a group and for categories of opioids by state and state-level MCLs from 2010 through 2015. Separate models were estimated first for whether the state had implemented any MCL and second for whether a state had implemented either a dispensary-based or a home cultivation only-based MCL. The primary outcome measure was the total number of daily opioid doses prescribed (in millions) in each US state for all opioids. The secondary analysis examined the association between MCLs separately by opioid class. From 2010 to 2015 there were 23.08 million daily doses of any opioid dispensed per year in the average state under Medicare Part D. Multiple regression analysis results found that patients filled fewer daily doses of any opioid in states with an MCL. The associations between MCLs and any opioid prescribing were statistically significant when we took the type of MCL into account: states with active dispensaries saw 3.742 million fewer daily doses filled (95% CI, -6.289 to -1.194); states with home cultivation only MCLs saw 1.792 million fewer filled daily doses (95% CI, -3.532 to -0.052). Results varied by type of opioid, with statistically significant estimated negative associations observed for hydrocodone and morphine. Hydrocodone use decreased by 2.320 million daily doses (or 17.4%) filled with dispensary-based MCLs (95% CI, -3.782 to -0.859; P = .002) and decreased by 1.256 million daily doses (or 9.4%) filled with home-cultivation-only-based MCLs (95% CI, -2.319 to -0.193; P = .02). Morphine use decreased by 0.361 million daily doses (or 20.7%) filled with dispensary-based MCLs (95% CI, -0.718 to -0.005; P = .047). Medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population. This finding was particularly strong in states that permit dispensaries, and for reductions in hydrocodone and morphine prescriptions.

Best practice strategies to safeguard drug prescribing and drug administration: an anthology of expert views and opinions.

PubMed

Seidling, Hanna M; Stützle, Marion; Hoppe-Tichy, Torsten; Allenet, Benoît; Bedouch, Pierrick; Bonnabry, Pascal; Coleman, Jamie J; Fernandez-Llimos, Fernando; Lovis, Christian; Rei, Maria Jose; Störzinger, Dominic; Taylor, Lenka A; Pontefract, Sarah K; van den Bemt, Patricia M L A; van der Sijs, Heleen; Haefeli, Walter E

2016-04-01

While evidence on implementation of medication safety strategies is increasing, reasons for selecting and relinquishing distinct strategies and details on implementation are typically not shared in published literature. We aimed to collect and structure expert information resulting from implementing medication safety strategies to provide advice for decision-makers. Medication safety experts with clinical expertise from thirteen hospitals throughout twelve European and North American countries shared their experience in workshop meetings, on-site-visits and remote structured interviews. We performed an expert-based, in-depth assessment of implementation of best-practice strategies to improve drug prescribing and drug administration. Workflow, variability and recommended medication safety strategies in drug prescribing and drug administration processes. According to the experts, institutions chose strategies that targeted process steps known to be particularly error-prone in the respective setting. Often, the selection was channeled by local constraints such as the e-health equipment and critically modulated by national context factors. In our study, the experts favored electronic prescribing with clinical decision support and medication reconciliation as most promising interventions. They agreed that self-assessment and introduction of medication safety boards were crucial to satisfy the setting-specific differences and foster successful implementation. While general evidence for implementation of strategies to improve medication safety exists, successful selection and adaptation of a distinct strategy requires a thorough knowledge of the institute-specific constraints and an ongoing monitoring and adjustment of the implemented measures.

Interns' knowledge of clinical pharmacology and therapeutics after undergraduate and on-going internship training in Nigeria: a pilot study

PubMed Central

Oshikoya, Kazeem A; Senbanjo, Idowu O; Amole, Olufemi O

2009-01-01

Background A sound knowledge of pathophysiology of a disease and clinical pharmacology and therapeutics (CPT) of a drug is required for safe and rational prescribing. The aim of this study was therefore to assess how adequately the undergraduate CPT teaching had prepared interns in Nigeria for safe and rational prescribing and retrospectively, to know how they wanted the undergraduate curriculum to be modified so as to improve appropriate prescribing. The effect of internship training on the prescribing ability of the interns was also sought. Methods A total of 100 interns were randomly selected from the Lagos State University Teaching Hospital (LASUTH), Ikeja; Lagos University Teaching Hospital (LUTH), Idiaraba; General Hospital Lagos (GHL); the EKO Hospital, Ikeja; and Havana Specialist Hospital, Surulere. A structured questionnaire was the instrument of study. The questionnaire sought information about the demographics of the interns, their undergraduate CPT teaching, experience of adverse drug reactions (ADRs) and drug interactions since starting work, confidence in drug usage and, in retrospect; any perceived deficiencies in their undergraduate CPT teaching. Results The response rate was 81%. All the respondents graduated from universities in Nigeria. The ability of the interns to prescribe rationally (66, 81.4%) and safely (47, 58%) was provided by undergraduate CPT teaching. Forty two (51.8%) respondents had problems with prescription writing. The interns would likely prescribe antibiotics (71, 87.6%), nonsteroidal analgesics (66, 81.4%), diuretics (55, 67.9%), sedatives (52, 62.9%), and insulin and oral hypoglycaemics (43, 53%) with confidence and unsupervised. The higher the numbers of clinical rotations done, the more confident were the respondents to prescribe unsupervised (χ2 = 19.98, P < 0.001). Similarly, respondents who had rotated through the four major clinical rotations and at least a special posting (χ2 = 11.57, P < 0.001) or four major clinical rotations only (χ2 = 11.25, P < 0.001) were significantly more confident to prescribe drugs unsupervised. Conclusion Undergraduate CPT teaching in Nigeria appears to be deficient. Principles of rational prescribing, drug dose calculation in children and pharmacovigilance should be the focus of undergraduate CPT teaching and should be taught both theoretically and practically. Medical students and interns should be periodically assessed on prescribing knowledge and skills during their training as a means of minimizing prescribing errors. PMID:19638199

Implementation in action: how Australian Exercise Physiologists approach exercise prescription for people with mental illness.

PubMed

Stanton, Robert; Rosenbaum, Simon; Lederman, Oscar; Happell, Brenda

2018-04-01

Accredited Exercise Physiologists (AEPs) are trained to deliver exercise and physical activity interventions for people with chronic and complex health conditions including those with mental illness. However, their views on exercise for mental illness, their exercise prescription practices, and need for further training are unknown. To examine the way in which Australian AEPs prescribe exercise for people with mental illness. Eighty-one AEPs (33.3 ± 10.4 years) completed an online version of the Exercise in Mental Illness Questionnaire. Findings are reported using descriptive statistics. AEPs report a high level of knowledge and confidence in prescribing exercise for people with mental illness. AEPs rate exercise to be at least of equal value to many established treatments for mental illness, and frequently prescribe exercise based on current best-practice principles. A need for additional training was identified. The response rate was low (2.4%) making generalisations from the findings difficult. Exercise prescription practices utilised by AEPs are consistent with current best-practice guidelines and there is frequent consultation with consumers to individualise exercise based on their preferences and available resources. Further training is deemed important.

Impact of a Mandatory Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by Dentists.

PubMed

Rasubala, Linda; Pernapati, Lavanya; Velasquez, Ximena; Burk, James; Ren, Yan-Fang

2015-01-01

Prescription Drug Monitoring Programs (PDMP) are statewide databases that collect data on prescription of controlled substances. New York State mandates prescribers to consult the PDMP registry before prescribing a controlled substance such as opioid analgesics. The effect of mandatory PDMP on opioid drug prescriptions by dentists is not known. This study investigates the impact of mandatory PDMP on frequency and quantity of opioid prescriptions by dentists in a dental urgent care center. Based on the sample size estimate, we collected patient records of a 3-month period before and two consecutive 3-month periods after the mandatory PDMP implementation and analyzed the data on number of visits, treatment types and drug prescriptions using Chi-square tests. For patients who were prescribed pain medications, 452 (30.6%), 190 (14.1%), and 140 (9.6%) received opioid analgesics in the three study periods respectively, signifying a statistically significant reduction in the number of opioid prescriptions after implementation of the mandatory PDMP (p<0.05). Total numbers of prescribed opioid pills in a 3-month period decreased from 5096 to 1120, signifying a 78% reduction in absolute quantity. Prescriptions for non-opioid analgesics acetaminophen increased during the same periods (p<0.05). We conclude that the mandatory PDMP significantly affected the prescription pattern for pain medications by dentists. Such change in prescription pattern represents a shift towards the evidence-based prescription practices for acute postoperative pain.

Impact of a Mandatory Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by Dentists

PubMed Central

Rasubala, Linda; Pernapati, Lavanya; Velasquez, Ximena; Burk, James; Ren, Yan-Fang

2015-01-01

Prescription Drug Monitoring Programs (PDMP) are statewide databases that collect data on prescription of controlled substances. New York State mandates prescribers to consult the PDMP registry before prescribing a controlled substance such as opioid analgesics. The effect of mandatory PDMP on opioid drug prescriptions by dentists is not known. This study investigates the impact of mandatory PDMP on frequency and quantity of opioid prescriptions by dentists in a dental urgent care center. Based on the sample size estimate, we collected patient records of a 3-month period before and two consecutive 3-month periods after the mandatory PDMP implementation and analyzed the data on number of visits, treatment types and drug prescriptions using Chi-square tests. For patients who were prescribed pain medications, 452 (30.6%), 190 (14.1%), and 140 (9.6%) received opioid analgesics in the three study periods respectively, signifying a statistically significant reduction in the number of opioid prescriptions after implementation of the mandatory PDMP (p<0.05). Total numbers of prescribed opioid pills in a 3-month period decreased from 5096 to 1120, signifying a 78% reduction in absolute quantity. Prescriptions for non-opioid analgesics acetaminophen increased during the same periods (p<0.05). We conclude that the mandatory PDMP significantly affected the prescription pattern for pain medications by dentists. Such change in prescription pattern represents a shift towards the evidence-based prescription practices for acute postoperative pain. PMID:26274819

Placebo prescription and empathy of the physician: A cross-sectional study.

PubMed

Braga-Simões, João; Costa, Patrício Soares; Yaphe, John

2017-12-01

Empathy in the patient-physician relationship is a major component in an effective placebo treatment, as in every medical treatment. Understanding the role of empathy of the physician in the placebo effect may help dissect some of the context variables responsible for the effectiveness of the placebo. To determine the frequency of placebo prescription, doctors' beliefs, motivation, and attitudes to placebos in general practice in northern Portugal and to test the association between placebo prescription and physician empathy. A cross-sectional study was conducted between November 2014 and January 2015 among general practice specialists and interns from 14 health centres in a northern Portuguese health region. The self-report questionnaire included the Portuguese version of the Jefferson scale of physician empathy (JSPE) and a questionnaire about placebo prescription. Associations between demographic variables, JSPE score, prescription of placebo, and the attitudes to placebo score were tested with the chi-squared statistic, student t-tests for independent samples, and Pearson correlation. The study included 93 general practitioners (GP) (response rate: 74%). Placebos were prescribed by 73% (n = 68) of the respondents. GPs who prescribe placebo are significantly younger (mean age = 38.4 years; SD = 11.1; t (90) = 2.98, P <.05, d = 0.67) than non-prescribers (mean age =46.5 years; SD =13.3). Favourable attitudes towards placebo prescription are associated with higher empathy scores (R = 0.310, P <.01). Placebo prescription is frequent and associated with empathy from the prescriber, especially among younger GPs.

Monitoring of Recommended Metabolic Laboratory Parameters Among Medicaid Recipients on Second-Generation Antipsychotics in Federally Qualified Health Centers.

PubMed

Uzal, Natalia E; Chavez, Benjamin; Kosirog, Emily R; Billups, Sarah J; Saseen, Joseph J

2018-02-01

In 2004, a consensus statement outlining recommended metabolic monitoring for patients prescribed second-generation antipsychotics (SGAs) was published. More than a decade later, suboptimal adherence rates to these recommendations continue to be reported, which could lead to long-term and costly complications. To define the prevalence of appropriately monitored Medicaid patients receiving care at federally qualified health centers (FQHCs) prescribed SGAs. This was a retrospective study examining electronic health record and Medicaid claims data to assess the rates of glucose and lipid monitoring for patients prescribed SGAs from January 2014 to August 2016 in a FQHC. Prescription and laboratory claims for patients receiving care at 4 FQHCs were reviewed. Descriptive statistics were used to evaluate the primary outcome. A total of 235 patients were included in the analysis. Patients initiated on SGA therapy (n = 92) had baseline glucose and lipid monitoring rates of 50% and 23%, respectively. The 3-month monitoring rates were 37% for glucose and 26% for lipids, whereas annual rates were 71% and 40%, respectively. Patients continuing SGA therapy (n = 143) had annual glucose and lipid monitoring rates of 67% and 44%. Medicaid patients at FQHCs initially prescribed SGAs have low baseline and 3-month metabolic monitoring, whereas annual monitoring was comparable to previously published studies. Adults receiving chronic care at a FQHC were more likely to receive glucose monitoring. Those with type 2 diabetes mellitus and/or hyperlipidemia were more likely to receive glucose and lipid monitoring.

OpenPrescribing: normalised data and software tool to research trends in English NHS primary care prescribing 1998-2016.

PubMed

Curtis, Helen J; Goldacre, Ben

2018-02-23

We aimed to compile and normalise England's national prescribing data for 1998-2016 to facilitate research on long-term time trends and create an open-data exploration tool for wider use. We compiled data from each individual year's national statistical publications and normalised them by mapping each drug to its current classification within the national formulary where possible. We created a freely accessible, interactive web tool to allow anyone to interact with the processed data. We downloaded all available annual prescription cost analysis datasets, which include cost and quantity for all prescription items dispensed in the community in England. Medical devices and appliances were excluded. We measured the extent of normalisation of data and aimed to produce a functioning accessible analysis tool. All data were imported successfully. 87.5% of drugs were matched exactly on name to the current formulary and a further 6.5% to similar drug names. All drugs in core clinical chapters were reconciled to their current location in the data schema, with only 1.26% of drugs not assigned a current chemical code. We created an openly accessible interactive tool to facilitate wider use of these data. Publicly available data can be made accessible through interactive online tools to help researchers and policy-makers explore time trends in prescribing. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Interdisciplinary optimum design. [of aerospace structures

NASA Technical Reports Server (NTRS)

Sobieszczanski-Sobieski, Jaroslaw; Haftka, Raphael T.

1986-01-01

Problems related to interdisciplinary interactions in the design of a complex engineering systems are examined with reference to aerospace applications. The interdisciplinary optimization problems examined include those dealing with controls and structures, materials and structures, control and stability, structure and aerodynamics, and structure and thermodynamics. The discussion is illustrated by the following specific applications: integrated aerodynamic/structural optimization of glider wing; optimization of an antenna parabolic dish structure for minimum weight and prescribed emitted signal gain; and a multilevel optimization study of a transport aircraft.

Governance structure reform and antibiotics prescription in community health centres in Shenzhen, China.

PubMed

Liang, Xiaoyun; Xia, Tingsong; Zhang, Xiulan; Jin, Chenggang

2014-06-01

It is unclear whether changing the governance structure of community health centres (CHCs) could affect antibiotic prescribing behaviour. To explore how changes in governance structure affect antibiotic prescription for children younger than 5 years of age with acute upper respiratory tract infections (AURI) in CHCs in Shenzhen, China. This study used an interrupted time series design with a comparison series. On 1 June 2009, the Health Bureau of Shenzhen's Baoan District transferred CHCs from a hospital-affiliated model to a self-managed independent model regarding finance, personnel and employee compensation. We collected 23481 electronic medical records of children younger than 5 years of age who were treated for AURI on an outpatient basis 1 year before and 1 year after governance structure reform. We used segmented regression analysis to evaluate the effect of reform on antibiotic prescription. After the reform, the proportion of patients receiving an antibiotic injection per month and the proportion of patients receiving two or more antibiotics conditional on receiving an antibiotic per month decreased 9.17% and 7.34%, respectively (P < 0.01 or P < 0.05). In the intervention series, the proportion of patients receiving an antibiotic injection per month and the monthly average cost of the antibiotics prescribed per patient continued to decrease over time compared with the control series (P < 0.001 or P < 0.05). This study suggests that governance structure reform can have positive effects on behaviour for antibiotic prescribing. Moreover, this short-term effect might have important implications for further community health reforms in China. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Recognition of pharmaceutical prescriptions across the European Union: a comparison of five Member States' policies and practices.

PubMed

Miguel, Lorena San; Augustin, Uta; Busse, Reinhard; Knai, Cécile; Rubert, Gloria; Sihvo, Sinikka; Baeten, Rita

2014-06-01

In 2011, the EU Directive on Patients' Rights in Cross Border Healthcare was approved, including a regulation on mutual recognition of prescriptions. To compare current national policies and practices on prescribing and dispensing, prescription-only medicines (POMs) in European countries in order to identify differences which could, challenge acceptance across borders. Semi-structured interviews with 37 national stakeholders were carried out. Furthermore, data on policies for prescribing and dispensing POMs were gathered based on desk research, and, contacts with relevant authorities via a purposely designed questionnaire. Important differences exist regarding: (1) information requirements for prescriptions to be, legally valid, (2) generic and international non-proprietary name (INN) policies and (3) professionals, legally allowed to prescribe POMs. Moreover, there is a lack of EU-wide access to key information for, validating prescriptions, recognizing the equivalence of products or identifying authorised prescribers. Differences in legislation and its application across Europe pose important challenges to be, addressed by policy makers with appropriate actions: (1) a prescribed product may not be dispensed, to a patient who needs it, (2) an inappropriate product (or inappropriate instructions) could be, provided and (3) POMs could be dispensed and consumed or sold, based on false prescriptions. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Relationships between bat occupancy and habitat and landscape structure along a savanna, woodland, forest gradient in the Missouri Ozarks

Treesearch

Clarissa A. Starbuck; Sybill K. Amelon; Frank R. III Thompson

2015-01-01

Many land-management agencies are restoring savannas and woodlands using prescribed fire and forest thinning, and information is needed on how wildlife species respond to these management activities. Our objectives were to evaluate support for relationships of bat site occupancy with vegetation structure and management and landscape composition and structure across a...

Fuel reduction treatments affect stand structure of hardwood forests in Western North Carolina and Southern Ohio, USA

Treesearch

Thomas A. Waldrop; Daniel A. Yaussy; Ross J. Phillips; Todd A. Hutchinson; Lucy Brudnak; Ralph E.J. Boerner

2008-01-01

Prescribed fire and mechanical treatments were tested at the two hardwood sites of the National Fire and Fire Surrogate Study (southern and central Appalachian regions) for impacts to stand structure. After two fires and one mechanical treatment, no treatment or treatment combination restored stand structure to historical levels. Burning alone had little impact on...

Jealousy Graphs: Structure and Complexity of Decentralized Stable Matching

DTIC Science & Technology

2013-01-01

REPORT Jealousy Graphs: Structure and Complexity of Decentralized Stable Matching 14. ABSTRACT 16. SECURITY CLASSIFICATION OF: The stable matching...Franceschetti 858-822-2284 3. DATES COVERED (From - To) Standard Form 298 (Rev 8/98) Prescribed by ANSI Std. Z39.18 - Jealousy Graphs: Structure and...market. Using this structure, we are able to provide a ner analysis of the complexity of a subclass of decentralized matching markets. Jealousy

Geophysical Measurements of Basalt Intraflow Structures.

DTIC Science & Technology

1997-12-01

COVERED Final 4. TITLE AND SUBTITLE Geophysical Measurements of Basalt Intraflow Structures 6. AUTHOR(S) William K. Hudson 7. PERFORMING...horm 29B (Hi ^ 29 ev. 5-88) by ANISE Sad Z39-18 Prescribed 298-102 GEOPHYSICAL MEASUREMENTS OF BASALT INTRAFLOW STRUCTURES by William K. Hudson A...region. The physical properties of basalt can change dramatically within a single flow and may be associated with changes in intraflow structure. The

Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing.

PubMed

Deckx, Laura; Anthierens, Sibyl; Magin, Parker J; Morgan, Simon; McArthur, Lawrie; Yardley, Lucy; Dallas, Anthea; Little, Paul; van Driel, Mieke L

2018-01-16

We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. To explore the participants' experiences with the intervention. A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Reasons for not prescribing guideline-recommended medications to adults with heart failure

PubMed Central

Steinman, Michael A.; Dimaano, Liezel; Peterson, Carolyn A.; Heidenreich, Paul A.; Knight, Sara J.; Fung, Kathy Z.; Kaboli, Peter J.

2013-01-01

Background Little is known about how often contextual factors such as patient preferences and competing priorities impact prescribing of guideline-recommended medications, or about the extent to which these factors are documented in medical records and available to performance measurement systems. Methods Mixed-methods study of 295 veterans age 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a beta blocker and/or an ACE inhibitor (ACE-I) or angiotensin receptor blocker (ARB). Reasons for non-treatment were identified from clinic notes and from interviews with 62 primary care clinicians caring for these patients. These reasons were classified using a published taxonomy. Results Among 295 patients not receiving guideline-recommended drugs for heart failure, chart review identified biomedical reasons for non-prescribing in 42-58% of patients and contextual reasons in 11-17%. Clinician interviews identified twice as many reasons for non-prescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P < .001). In these interviews, biomedical reasons for non-prescribing were cited in 50-70% of patients, and contextual reasons in 64-70%. The most common contextual reasons were co-management with other clinicians (32-35% of patients), patient preferences and non-adherence (15-24%), and clinician belief that the medication is not indicated in the patient (12-20%). Conclusions Contextual reasons for not prescribing ACE-I/ARBs and beta blockers are present in two-thirds of patients with heart failure who did not receive these medications, yet are poorly documented in medical records. The structure of medical records should be improved to facilitate documentation of contextual reasons for not providing guideline-recommended care. PMID:23969589

Knowledge Claims, Jurisdictional Control and Professional Status: The Case of Nurse Prescribing

PubMed Central

Kroezen, Marieke; van Dijk, Liset; Groenewegen, Peter P.; Francke, Anneke L.

2013-01-01

Over the past decades, professional boundaries in health care have come under pressure, and the expansion of prescriptive authority to include nurses touches on issues of professional domains and interprofessional competition. Knowledge claims play an important role in achieving jurisdictional control. Knowledge can take on multiple forms, ranging from indeterminate to technical (I/T ratio) and from everyday to exclusive knowledge. To investigate the interrelatedness of jurisdiction, knowledge claims and professional status, we examine which knowledge claims were made by the medical and nursing professions in the Netherlands to secure or obtain, respectively, jurisdictional control over prescribing, and which form this knowledge took. The study is based on thirteen semi-structured stakeholder interviews and an extensive document analysis. We found that the nursing profession in its knowledge claims strongly emphasized the technicality and everyday knowledge character of the prescribing task, by asserting that nurses were already prescribing medicines, albeit on an illegal basis. Their second claim focused on the indeterminate knowledge skills of nurses and stated that nurse prescribing would do justice to nurses’ skills and expertise. This is a strong claim in a quest for (higher) professional status. Results showed that the medical profession initially proclaimed that prescribing should be reserved for doctors as it is a task requiring medical knowledge, i.e. indeterminate knowledge. Gradually, however, the medical profession adjusted its claims and tried to reduce nurse prescribing to a task almost exclusively based on technicality knowledge, among others by stating that nurses could prescribe in routine cases, which would generate little professional status. By investigating the form that professional knowledge claims took, this study was able to show the interconnectedness of jurisdictional control, knowledge claims and professional status. Knowledge claims are not mere rhetoric, but actively influence the everyday realities of professional status, interprofessional competition and jurisdictional division between professions. PMID:24124613

Teaching exercise of drug utilization by medical students.

PubMed

Das, B P; Sethi, A; Nutan, K; Gunjan

2005-01-01

The prescription is a vital written document communicating between the physician, the patient and the pharmacist. The audit of prescribing pattern is a component of medical audit, which seeks monitoring, evaluation and necessary modifications in the prescribing practices of prescribers to achieve rational and cost effective medical care for the patients, The present drug utilization study was conducted by fourth year MBBs students during their research posting in the department of Pharmacology at B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan. The prescriptions were randomly collected from BPKIHS pharmacy over a period of 3 weeks. The auditing was done in the form of a semi structured performa containing the patients particulars with regard to age, sex, and residence, the details of the illness and prescribed drug information. The data was analyzed at the end of the study. The study points out that the maximum (27.5%) prescriptions were from General Outpatient Department (GOPD) followed by ENT (16.5%), Internal medicine (15.5%) and General surgery (10%). This indicates the distribution of patient load in hospital and the dominant areas to be targeted for intervention. Further, the proportion of antimicrobial agents (AMAs) i.e. 26.03% use was low and was prescribed empirically in most of the cases. There was use of expensive AMAs and irrational prescribing of combinations of AMAs in some prescriptions. Other prevailing drugs which were prescribed were analgesics. The usage of nimesulide and rofecoxib. withdrawn by FDA were used recurrently in this setup. There was greater use of dubious drugs of unproven benefit like vitamins, calcium etc. The diagnosis of the disease were not mentioned in 32.5% of prescriptions, The dose, frequency and duration of drugs were unascertained in majority of prescriptions that might lead to health hazards. This exercise might change the behavior of existing prescribers and also of the future doctors.

Analysis of the structural behaviour of colonic segments by inflation tests: Experimental activity and physio-mechanical model.

PubMed

Carniel, Emanuele L; Mencattelli, Margherita; Bonsignori, Gabriella; Fontanella, Chiara G; Frigo, Alessandro; Rubini, Alessandro; Stefanini, Cesare; Natali, Arturo N

2015-11-01

A coupled experimental and computational approach is provided for the identification of the structural behaviour of gastrointestinal regions, accounting for both elastic and visco-elastic properties. The developed procedure is applied to characterize the mechanics of gastrointestinal samples from pig colons. Experimental data about the structural behaviour of colonic segments are provided by inflation tests. Different inflation processes are performed according to progressively increasing top pressure conditions. Each inflation test consists of an air in-flow, according to an almost constant increasing pressure rate, such as 3.5 mmHg/s, up to a prescribed top pressure, which is held constant for about 300 s to allow the development of creep phenomena. Different tests are interspersed by 600 s of rest to allow the recovery of the tissues' mechanical condition. Data from structural tests are post-processed by a physio-mechanical model in order to identify the mechanical parameters that interpret both the non-linear elastic behaviour of the sample, as the instantaneous pressure-stretch trend, and the time-dependent response, as the stretch increase during the creep processes. The parameters are identified by minimizing the discrepancy between experimental and model results. Different sets of parameters are evaluated for different specimens from different pigs. A statistical analysis is performed to evaluate the distribution of the parameters and to assess the reliability of the experimental and computational activities. © IMechE 2015.

Robust inertia-free attitude takeover control of postcapture combined spacecraft with guaranteed prescribed performance.

PubMed

Luo, Jianjun; Wei, Caisheng; Dai, Honghua; Yin, Zeyang; Wei, Xing; Yuan, Jianping

2018-03-01

In this paper, a robust inertia-free attitude takeover control scheme with guaranteed prescribed performance is investigated for postcapture combined spacecraft with consideration of unmeasurable states, unknown inertial property and external disturbance torque. Firstly, to estimate the unavailable angular velocity of combination accurately, a novel finite-time-convergent tracking differentiator is developed with a quite computationally achievable structure free from the unknown nonlinear dynamics of combined spacecraft. Then, a robust inertia-free prescribed performance control scheme is proposed, wherein, the transient and steady-state performance of combined spacecraft is first quantitatively studied by stabilizing the filtered attitude tracking errors. Compared with the existing works, the prominent advantage is that no parameter identifications and no neural or fuzzy nonlinear approximations are needed, which decreases the complexity of robust controller design dramatically. Moreover, the prescribed performance of combined spacecraft is guaranteed a priori without resorting to repeated regulations of the controller parameters. Finally, four illustrative examples are employed to validate the effectiveness of the proposed control scheme and tracking differentiator. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross-sectional Survey Among 185 Medical Schools in 27 Countries.

PubMed

Brinkman, D J; Tichelaar, J; Okorie, M; Bissell, L; Christiaens, T; Likic, R; Mačìulaitis, R; Costa, J; Sanz, E J; Tamba, B I; Maxwell, S R; Richir, M C; van Agtmael, M A

2017-11-01

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real-life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU. © 2017 The Authors Clinical Pharmacology & Therapeutics published by Wiley Periodicals, Inc. on behalf of American Society for Clinical Pharmacology and Therapeutics.

The prescribing of specialist medicines: what factors influence GPs' decision making?

PubMed

Crowe, Sarah; Tully, Mary P; Cantrill, Judith A

2009-08-01

As Governments worldwide strive to integrate efficient health care delivery across the primary-secondary care divide, particular significance has been placed on the need to understand GPs' prescribing of specialist drugs. To explore the factors which influence GPs' decision-making process when requested to prescribe specialist drugs. A qualitative approach was used to explore the perspectives of a wide range of practice-, primary care trust-, strategic health authority-level staff and other relevant stakeholders in the North-West of England. All semi-structured interviews (n = 47) were analysed comprehensively using the five-stage 'framework' approach. Six diverse factors were identified as having a crucial bearing on how GPs evaluate initial requests and subsequently decide whether or not to prescribe. These include GPs' lack of knowledge and expertise in using specialist drugs, the shared care arrangement, the influence of a locally agreed advisory list, financial and resource considerations, patient convenience and understanding and GPs' specific areas of interest. This exploration of GPs' decision-making process is needed to support future integrated health care delivery.

Chapter 9 - Monitoring survival of fire-injured trees in Oregon and Washington (Project WC-F-08-03)

Treesearch

Robert A. Progar; Lisa Ganio; Lindsay Grayson; Sharon M. Hood

2018-01-01

Wild and prescribed fire injury to trees can produce mortality that is not immediately apparent, and environmental stress subsequent to a fire may also contribute to tree mortality in the years after a fire (Hood and Bentz 2007). In order to predict post-fire tree mortality from fire injury variables before tree mortality is clearly apparent, dozens of statistical...

Barriers to accepting e-prescribing in the U.S.A.

PubMed

Smith, Alan D

2006-01-01

With the number of prescriptions rising nationally each year, it is surprising that Web-based technology is not fully embraced in the pharmacy industry as an aid to quality-assuring prescribing processes. Traditional prescription handling is done in a manual fashion with physicians hand-writing prescriptions for the patients during an office visit, giving the patient the responsibility of taking the prescription to a pharmacy or mailing the prescription to a mail order company for fulfillment. Electronic prescribing (e-prescribing) has the ability not only to streamline the prescription writing process, but also to reduce the number of errors that may be incurred with hand-written prescriptions. The purpose of this paper is to investigate these phenomena in the U.S.A. A number of hypotheses were tested using principal-components analysis (PCA) and factor analyses. As a result, a total of 55 fully employed, professional and semi-professional service management and internet users, representing a college-educated and knowledge-based sample derived from the metropolitan section of Pittsburgh, was selected. The six major constructs generated from the factor loadings in descending order of importance were: profit and risk factors, shipping and handling, saving, customer relationship management (CRM) and ethics, age, and awareness. The dependent variable chosen to be regressed against these major independent factor-based constructs was willingness to purchase prescriptions online. The overall relationship was found to be statistically significant (F = 2.971, p = 0.015) in predicting willingness to use e-prescribing options based on the various independent constructs. However, when testing the various standardized beta coefficients in the linear model, only the factor score-based construct CRM and ethics was found to significantly contribute to predicting the willingness to purchase prescriptions online (t = -3.074, p = 0.003). Although this study appears to represent the e-prescribing process in the U.S.A., the sample size and region studied are only one slice of the general population. Practical implications - Unfortunately, the adoption of e-prescribing has been difficult to attain owing to numerous barriers throughout the industry. Such acceptance barriers include lack of technology trust, associated system costs, and risk of un-securing patient health and medical information. This article documents that increasing numbers of pharmacies today are building their IT-infrastructures to accept electronic prescriptions and it may soon be the preferred method for physicians to write prescriptions. It is with great anticipation that this technology will also enhance the prescription-writing abilities of prescribing physicians globally, giving them electronic access to patient medical records and resources that will assist them in prescribing the correct drug for the patient.

An exploration of how nurse prescribing is being used for patients with respiratory conditions across the east of England

PubMed Central

2014-01-01

Background There is a need to reduce symptoms, exacerbations and improve quality of life for patients with respiratory diseases. Across the world, increasing numbers of nurses are adopting the prescribing role and can potentially enhance service provision. Evidence suggests improved quality of care and efficiencies occur when nurses adopt the prescribing role. No evidence is available on the views of nurse prescribers who care for respiratory patients. The aim was to explore how nurse prescribing is being used for patients with respiratory conditions in different care settings across one strategic health authority, and whether this has benefited patients, healthcare professionals and the National Health Service. Methods A qualitative study involving semi-structured interviews with a purposive sample of 40 nurses who prescribed for respiratory patients across the six counties in the East of England Strategic Health Authority. Data were collected in 2011 and subject to thematic analysis. Results Disease management, including treatment and prevention of exacerbations, emergency episodes and minor illness, optimising and co-ordinating care were key aspects of care provided. Findings are reported under three themes: access, adherence and risk management and impact on nurses. Prescribing enabled nurses overcome existing problems in service provision to improve access, efficiency and patient convenience, reducing hospital admissions and length of stay. It also enabled patient centered consultations, which encouraged self-management, improved adherence, helped manage expectations, and reduced inappropriate service use. While participants experienced increased job satisfaction, knowledge and confidence, concerns were raised about increased responsibility, support, governance and future commissioning of services in line with planned major changes to the National Health Service. Conclusions This study provides new knowledge about how nurse prescribers provide care to patients with respiratory diseases. Despite a lack of consensus over the most effective model of respiratory care, prescribing was reported to have improved and extended points of access to treatment, and supported management of complex patients, particularly vulnerable groups. Given the high burden of chronic respiratory disease to patients and families this has important implications that need to be considered by those responsible for commissioning services in the United Kingdom and other countries. PMID:24443796

Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views.

PubMed

Stenner, Karen L; Courtenay, Molly; Carey, Nicola

2011-01-01

There is a drive to improve the quality of service provision for patients with diabetes and to enable better self-management of this condition. The adoption of prescribing by nurses is increasing worldwide and can potentially enhance service provision. Evidence suggests that patients prefer services where their lifestyle factors and opinions are considered by healthcare professionals within a partnership approach. Few studies have explored patients' views about their consultations with a nurse prescriber. To explore the views patients with diabetes have about their consultations with nurse prescribers and any impact this may have on their medications management. A qualitative study involving semi-structured interviews and thematic analysis. Six primary care sites in which nurses prescribed medications for patients with diabetes in England. Data was collected in 2009. Interviews took place with 41 patients with diabetes from the case loads of 7 nurse prescribers. Findings are reported under three themes; the nurse consultation style, benefits of the nurse prescriber consultation and views on involvement and decision-making. Key aspects of the nurse consultation style were a non-hurried approach, care and rapport, approachability, continuity, and providing clear information based on specialist knowledge. Many benefits were described, including improved access to appropriate advice and medication, greater understanding and ability to self-manage, ability to address problems and improved confidence, trust and wellbeing. While patients were happy with the amount of information received and involvement they had decisions about their treatment, there was some controversy over the consistency of information provided on side-effects of treatment. The study provides new knowledge about what patients with diabetes value and benefit from in respect to care provided by nurse prescribers. Continuity of relationship, flexibility over consultation length, nurses' interpersonal skills and specialist diabetes knowledge were identified as crucial to good quality care. Patients require that nurse prescribers are skilled in providing a person-centred approach and have access to specialist training. The level of information and involvement offered to patients should reflect patients' requirements. Copyright © 2010 Elsevier Ltd. All rights reserved.

Antibiotic prescribing in women during and after delivery in a non-teaching, tertiary care hospital in Ujjain, India: a prospective cross-sectional study.

PubMed

Sharma, Megha; Sanneving, Linda; Mahadik, Kalpana; Santacatterina, Michele; Dhaneria, Suryaprakash; Stålsby Lundborg, Cecilia

2013-01-01

Antibacterial drugs (hereafter referred to as antibiotics) are crucial to treat infections during delivery and postpartum period to reduce maternal mortality. Institutional deliveries have the potential to save lives of many women but extensive use of antibiotics, add to the development and spread of antibiotic resistance. The aim of this study was to present antibiotic prescribing among inpatients during and after delivery in a non-teaching, tertiary care hospital in the city of Ujjain, Madhya Pradesh, India. A prospective cross-sectional study was conducted including women having had either a vaginal delivery or a cesarean section in the hospital. Trained nursing staff collected the data on daily bases, using a specific form attached to each patient file. Statistical analysis, including bivariate and multivariable logistic regression was conducted. Of the total 1077 women, 566 (53%) had a vaginal delivery and 511 (47%) had a cesarean section. Eighty-seven percent of the women that had a vaginal delivery and 98% of the women having a cesarean section were prescribed antibiotics. The mean number of days on antibiotics in hospital for the women with a vaginal delivery was 3.1 (±1.7) and for the women with cesarean section was 6.0 (±2.5). Twenty-eight percent of both the women with vaginal deliveries and the women with cesarean sections were prescribed antibiotics at discharge. The most commonly prescribed antibiotic group in the hospital for both the women that had a vaginal delivery and the women that had a cesarean section were third-generation cephalosporins (J01DD). The total number of defined daily doses (DDD) per100 bed days for women that had a vaginal delivery was 101, and 127 for women that had a cesarean section. The high percentage of women having had a vaginal delivery that received antibiotics and the deviation from recommendation for cesarean section in the hospital is a cause of concern. Improved maternal health and rational use of antibiotics are intertwined. Specific policy and guidelines on how to prescribe antibiotics during delivery at health care facilities are needed. Additionally, monitoring system of antibiotic prescribing and resistance needs to be developed and implemented.

Paramedical staffs knowledge and attitudes towards antimicrobial resistance in Dire Dawa, Ethiopia: a cross sectional study.

PubMed

Tafa, Belay; Endale, Adugna; Bekele, Desalegn

2017-09-19

The continuing emergence, development and spread of pathogenic organisms that are resistant to antimicrobials are a cause of increasing concern. The control of antimicrobial resistance requires knowledge of factors causing antimicrobial resistance, good attitudes towards the intervention strategies as well as changes in antibiotic prescribing behavior of health workers. Hence, this study was aimed to assess paramedical staffs' knowledge and attitudes towards antimicrobial resistance and their antibiotics prescription practices in Dire Dawa, Ethiopia. A cross-sectional survey was conducted among paramedical staffs working in hospitals and health centers. A total of 218 paramedical staffs were participated and a self-administered questionnaire was used to collect data. Data was analyzed using SPSS version 20. Chi square/Fisher's exact tests were used for comparison of data and a p value of less than 0.05 was considered statistically significant. Out of the total, 137 (62.8%) of paramedical staffs had good knowledge on the factors causing antimicrobial resistance. The most common causes of antimicrobial resistance reported were patients' poor adherence (96.5%), self prescription (95%), and empiric choice of antibiotics (94.5%). In general, more than 80% of the respondents had positive attitudes towards the antimicrobials resistance intervention strategies. Relatively less proportion of participants recognized that antimicrobial resistance as a problem in their local institutions. The most perceived driving forces for unnecessary antibiotics prescriptions were treatment failure (67.7%) and patient push (53.3%). The majority, 76.9% of the prescribers mentioned that standard treatment guidelines were available in their institutions though only 15.7% of them reported referring the guidelines on the daily basis. Among the prescribers, 85.8% never attended formal trainings on antibiotics prescriptions. As this study generated important information on knowledge and attitudes of paramedical staffs about antimicrobial resistance, it identified areas of misconceptions and specific groups to be targeted for educational interventions regarding antimicrobial resistance. It is, therefore, suggested that a well-planned, organized and structured training programs should be undertaken to improve the appropriate use of antibiotics.

14 CFR 25.345 - High lift devices.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS: TRANSPORT CATEGORY AIRPLANES Structure Flight Maneuver and Gust Conditions § 25.345 High lift... level flight. Gust loads resulting on each part of the structure must be determined by rational analysis... prescribed in § 25.337(b); and (2) The discrete vertical gust criteria in § 25.341(a). (d) The airplane must...

14 CFR 25.345 - High lift devices.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS: TRANSPORT CATEGORY AIRPLANES Structure Flight Maneuver and Gust Conditions § 25.345 High lift... level flight. Gust loads resulting on each part of the structure must be determined by rational analysis... prescribed in § 25.337(b); and (2) The discrete vertical gust criteria in § 25.341(a). (d) The airplane must...

14 CFR 25.345 - High lift devices.

Code of Federal Regulations, 2013 CFR

2013-01-01

... STANDARDS: TRANSPORT CATEGORY AIRPLANES Structure Flight Maneuver and Gust Conditions § 25.345 High lift... level flight. Gust loads resulting on each part of the structure must be determined by rational analysis... prescribed in § 25.337(b); and (2) The discrete vertical gust criteria in § 25.341(a). (d) The airplane must...

Time trends in intracranial bleeding associated with direct oral anticoagulants: a 5-year cohort study

PubMed Central

Hogg, Kerstin; Bahl, Bharat; Latrous, Meriem; Scaffidi Argentina, Sarina; Thompson, Jesse; Chatha, Aasil Ayyaz; Castellucci, Lana; Stiell, Ian G.

2015-01-01

Background: Over the past 5 years, dabigatran, rivaroxaban and apixaban were approved for stroke prevention. Phase III studies have shown a lower risk of intracranial bleeding with these direct oral anticoagulants than with warfarin; however, there is a lack of real-life data to validate this. We analyzed time trends in atraumatic intracranial bleeding from 2009 to 2013 among patients prescribed oral anticoagulants and those not prescribed oral anticoagulants. Methods: We used ICD-10-CA (enhanced Canadian version of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) codes to identify all patients with atraumatic intracranial bleeding who presented to our neurosurgical centre (serving a population of more than 1.2 million). Trained researchers extracted data on anticoagulant medications used in the week before diagnosis of the intracranial bleed. Provincial prescription data for oral anticoagulants were obtained from IMS Brogan CompuScript Market Dynamics. The primary outcome was the time trend in incident intracranial bleeds associated with oral anticoagulation during the period 2009-2013. The secondary outcomes were the time trend in intracranial bleeds not associated with oral anticoagulation and the provincial prescribing patterns for oral anticoagulants during the same period. Results: A total of 2050 patients presented with atraumatic intracranial bleeds during the study period. Of the 371 (18%) prescribed an anticoagulant in the week before presentation, 335 were prescribed an oral anticoagulant. There was an increasing time trend in intracranial bleeding associated with oral anticoagulants (p = 0.009; 6 additional events per year) and in intracranial bleeding not associated with oral anticoagulation (p = 0.06). During 2013, prescriptions for warfarin decreased to 70% of all oral anticoagulant prescriptions in the province, whereas those for dabigatran and rivaroxaban increased to 17% and 12%, respectively. Interpretation: We observed increasing time trends in intracranial bleeding, both associated with and not associated with oral anticoagulants, over the study period. Although aggregate provincial data showed increased prescribing of oral anticoagulants, other more likely explanations for our findings include an aging population or increasing frailty. PMID:26770966

Effects of prescribed fire on vegetation and passerine birds in northern mixed-grass prairie

USGS Publications Warehouse

Grant, T.A.; Madden, E.M.; Shaffer, T.L.; Dockens, J.S.

2010-01-01

Prescribed fire is used widely to manage grasslands on National Wildlife Refuges and other public lands in the northern Great Plains, but its effects on habitat use or production of wildlife in the region are poorly understood. During 19982003, we used point counts to examine effects of prescribed fire on vegetation and passerines in a mixed-grass prairie complex in north-central North Dakota, USA (n 7 units, each 4070 ha). Vegetation structure and, to a lesser extent, plant community composition varied with year of study (likely related to changes in annual precipitation) and with number of growing seasons since fire. Fire altered plant structure, especially the amount of residual vegetation, which in turn influenced bird species richness and abundance. The number of indicated pairs for sedge wren (Cistothorus platensis), clay-colored sparrow (Spizella pallida), Le Conte's sparrow (Ammodramus leconteii), Savannah sparrow (Passerculus sandwichensis), and bobolink (Dolichonyx oryzivorus) were lowest during the first postfire growing season but generally increased and stabilized within 23 postfire growing seasons. Our results support the premise that grassland passerines are well-adapted to frequent, periodic fires, generally corresponding to those occurring prior to EuroAmerican settlement of the region. Prescribed fire is important for reducing tree and shrub invasion, restoring biological integrity of plant communities, and maintaining or enhancing populations of grassland-dependent bird species. Managers in the northern mixed-grass prairie region should not be overly concerned about reductions in bird abundances that are limited mostly to the first growing season after fire. 2010 The Wildlife Society.

Physicians' opinions about responsibility for patient out-of-pocket costs and formulary prescribing in two Midwestern states.

PubMed

Khan, Shamima; Sylvester, Robert; Scott, David; Pitts, Bruce

2008-10-01

Multi-tier copayment designs in pharmacy benefit plans are intended to steer patients and prescribers to preferred drug therapies that have lower out-of-pocket costs for patients. To describe and assess physicians' prescribing experiences and opinions in a multi-tier, primarily 3-tier formulary environment in 2 Midwestern states. This was a cross-sectional survey of physicians practicing in either Minnesota or North Dakota. A packet consisting of a survey instrument, a cover letter, and a postage-paid return envelope was mailed to a random sample of 690 physician members of the Minnesota Medical Association (n = 460, 5.1% of members) or the North Dakota Medical Association (n = 230, 25.6% of members). Surveys were mailed between March and May 2006. Nonresponders were mailed up to 2 additional surveys. Survey items included practice specialty, sources used to obtain drug information, perceived importance of cost containment actions (e.g., prescribing drug with lowest total cost, prescribing drug that minimizes patient out-of-pocket cost), and how often the physician was personally aware of the following when writing a prescription: identity of the patient's insurer, patient's pharmacy benefit structure, preferred medications on the insurer's formulary, patient's copayment (out-of-pocket cost) responsibility, and list price of the medication. The survey response rate was 49.8% (296 of 594). The results were as follows: 93.5% of respondents agreed that it was important to prescribe the drug that would minimize the patient's out-of-pocket costs, 73.2% agreed that it was important to discuss out-of-pocket medication costs with patients, 81.8% of respondents agreed that it was important to prescribe the drug with the lowest total costs, and 33.3% of respondents believed that it was their responsibility to prescribe a preferred (formulary) medication. According to the survey, 61.6% of respondents were rarely or never aware of their patient's copayment amounts, and 42.4% were rarely or never aware of the list price of the medication. Physician specialty was associated with the awareness of the identity of the patient's insurer (generalists, 41.1% vs. specialists, 19.2%; P = 0.001) and use of personal digital assistant (PDA) when prescribing (generalists, 38.9% vs. specialists, 21.1%; P = 0.005). Physicians who responded to this survey believed that it was important to prescribe drugs that would minimize patients' prescription copayments, but they were often unaware of the preferred medications on the formulary, the patients' copayment amounts, or the price of the drugs prescribed.

A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications.

PubMed

Bowers, Ben; Redsell, Sarah A

2017-10-01

The aim of this study was to explore community nurses' decision-making processes around the prescribing of anticipatory medications for people who are dying. Community nurses frequently initiate the prescribing of anticipatory medications to help control symptoms in those who are dying. However, little is known about their decision-making processes in relation to when they instigate anticipatory prescribing and their discussions with families and General Practitioners. A qualitative interpretive descriptive enquiry. A purposive sample of 11 Community Palliative Nurses and District Nurses working in one geographical area participated. Data were collected between March and June 2016 via audio recorded semi-structured interviews and analysed inductively using Braun and Clarke's thematic analysis. Three themes were identified: (1) Drugs as a safety net. Anticipatory medications give nurses a sense of control in last days of life symptom management; (2) Reading the situation. The nurse judges when to introduce conversations around anticipatory medications, balancing the need for discussion with the dying person and their family's likely response; (3) Playing the game. The nurse owns the decision to initiate anticipatory medication prescribing and carefully negotiates with the General Practitioner. Nurses view pain control through prescribed medication as key to symptom management for dying people. Consequently, they own the role of ascertaining when to initiate discussions with families about anticipatory medicines. Nurses believe they advocate for dying person and their families' needs and lead negotiations with General Practitioners for medications to go into the home. This nurse led care alters the traditional boundaries of the General Practitioners-nurse professional relationship. © 2017 John Wiley & Sons Ltd.

14 CFR 23.343 - Design fuel loads.

Code of Federal Regulations, 2010 CFR

2010-01-01

...) Gust velocities equal to 85 percent of the values prescribed in § 23.333(c). (2) The fatigue evaluation of the structure must account for any increase in operating stresses resulting from the design...

Glutamine supplemented parenteral nutrition to prevent ventilator-associated pneumonia in the intensive care unit.

PubMed

Aydoğmuş, Meltem Türkay; Tomak, Yakup; Tekin, Murat; Katı, Ismail; Hüseyinoğlu, Urfettin

2012-12-01

Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. No statistically significant difference was found among groups in terms of development of VAP (p=0.622). Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP.

The long-term use of benzodiazepines: patients' views, accounts and experiences.

PubMed

Barter, G; Cormack, M

1996-12-01

Although a decrease in new prescribing has occurred for anxiolytic benzodiazepines, concerns have been raised that a 'core' of long-term users has been left behind. Typically, elderly people represent this 'core', using the benzodiazepines as hypnotics. The present study focuses on the reasons why hypnotic benzodiazepines are used for protracted lengths of time. By examining patient experiences and cognitions, a deeper understanding may be gained of why patients continue to use benzodiazepines. Elderly, long-term users of benzodiazepine hypnotics were interviewed using a semi-structured interview procedure. A comparison group of non-users of the drugs were given a brief interview to collect comparative data. Interview data were analysed from transcripts using qualitative methodology; statistical comparisons between the groups were made using non-parametric statistics. The long-term users had significantly fewer hours of sleep per night than the non-users. There was some evidence of tolerance and a suggestion that symptoms of withdrawal were maintaining continual use. None of the long-term users had clean knowledge of what their doctors thought of their use of benzodiazepines. The data suggest that the power of the doctor may not be utilized to its full potential in the prevention of long-term use, that at least 50% of elderly benzodiazepine users would like to discontinue use, and that patients need information and advice on how to discontinue these drugs.

Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan

PubMed Central

Teich, Jonathan M.; Osheroff, Jerome A.; Pifer, Eric A.; Sittig, Dean F.; Jenders, Robert A.

2005-01-01

Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption. PMID:15802474

Can price controls reduce pharmaceutical expenses? A case study of antibacterial expenditures in 12 Chinese hospitals from 1996 to 2005.

PubMed

Han, Sheng; Liang, Huigang; Su, Weiping; Xue, Yajiong; Shi, Luwen

2013-01-01

The objective of this article is to investigate whether the Chinese government's pricing policies have reduced pharmaceutical expenses. The purchasing records for systemic antibacterial drugs of 12 hospitals in Beijing from 1996 to 2005 were analyzed by separating the expenditure growth into three components: the price change, the volume change, and the structure change. Our results reveal that the structure change is the dominant determinant of drug expenditure growth. Despite lowered prices, the antibacterial drug expenditure was raised because more expensive drugs in the same therapeutic category were prescribed. It is insufficient to rely only on pricing policies to reduce drug expenses, given that physicians could circumvent the policy by prescribing more expensive drugs. In addition, physician behaviors need to be regulated to eliminate unnecessary overprescribing.

Dynamic balance in turbulent reconnection

NASA Astrophysics Data System (ADS)

Yokoi, N.; Higashimori, K.; Hoshino, M.

2012-12-01

Dynamic balance between the enhancement and suppression of transports due to turbulence in magnetic reconnection is discussed analytically and numerically by considering the interaction of the large-scale field structures with the small-scale turbulence in a consistent manner. Turbulence is expected to play an important role in bridging small and large scales related to magnetic reconnection. The configurations of the mean-field structure are determined by turbulence through the effective transport. At the same time, statistical properties of turbulence are determined by the mean-field structure through the production mechanisms of turbulence. This suggests that turbulence and mean fields should be considered simultaneously in a self-consistent manner. Following the theoretical prediction on the interaction between the mean-fields and turbulence in magnetic reconnection presented by Yokoi and Hoshino (2011), a self-consistent model for the turbulent reconnection is constructed. In the model, the mean-field equations for compressible magnetohydrodynamics are treated with the turbulence effects incorporated through the turbulence correlation such as the Reynolds stress and turbulent electromotive force. Transport coefficients appearing in the expression for these correlations are not adjustable parameters but are determined through the transport equations of the turbulent statistical quantities such as the turbulent MHD energy, the turbulent cross helicity. One of the prominent features of this reconnection model lies in the point that turbulence is not implemented as a prescribed one, but the generation and sustainment of turbulence through the mean-field inhomogeneities are treated. The theoretical predictions are confirmed by the numerical simulation of the model equations. These predictions include the quadrupole cross helicity distribution around the reconnection region, enhancement of reconnection rate due to turbulence, localization of the reconnection region through the cross-helicity effect, etc. Some implications to the satellite observation of the magnetic reconnection will be also given. Reference: Yokoi, N. and Hoshino, M. (2011) Physics of Plasmas, 18, 111208.

Willingness-to-pay function for two fuel treatments to reduce wildfire acreage burned: A scope test and comparison of white and hispanic households

Treesearch

John B. Loomis; Hung Le Trong; Armando González-Cabán

2009-01-01

We estimate a marginal benefit function for using prescribed burning and mechanical fuel reduction programs to reduce acres burned by wildfire in three states. Since each state had different acre reductions, a statistically significant coefficient on the reduction in acres burned is also a split sample scope test frequently used as an indicator of the internal validity...

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial.

PubMed

Maughan, Brandon C; Hersh, Elliot V; Shofer, Frances S; Wanner, Kathryn J; Archer, Elizabeth; Carrasco, Lee R; Rhodes, Karin V

2016-11-01

Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher's exact p=0.11). Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery. Copyright © 2016. Published by Elsevier Ireland Ltd.

Dependence to legally prescribed opioid analgesics in a university hospital in Medellin-Colombia: an observational study.

PubMed

Garcia-Orjuela, Maria G; Alarcon-Franco, Lineth; Sanchez-Fernandez, Juan C; Agudelo, Yuli; Zuluaga, Andres F

2016-09-14

In some countries the misuse and diversion of prescribed opioid analgesic is increasing considerably, but there is no official data regarding the situation in Colombia. The aim of this study was to identify all dependent to opioid analgesics legally prescribed patients that were treated in a University Hospital in Medellin, Colombia during 4 years and to characterize this population. Observational study in a University Hospital in Medellin, Colombia, searching for patients with ICD-10 codes related with opioid related disorders, adverse events or pain and treated between January 2011 and December 2014. Sixty patients with opioid dependence according to DSM-IV criteria were found from 3332 clinical charts reviewed. The median age was 43 years. Although all patients met the DSM-IV criteria, 33 % of patients were wrongly diagnosed by other ICD-10 codes. Almost all patient (88 %) initiated opioids after medical prescription although the adherence to pain scale was low (25 %). The median time of consumption was 48 months. Tramadol was the opioid more frequently used by patients, followed by morphine and oxycodone. A statistically significant higher consumption of other psychotropic substances was observed in male than female (P = 0.005 by Fisher's test). After be diagnosed, 55 % of patients gone a methadone-based replacement therapy. Legally prescribed opioid dependence was belatedly diagnosed in 60 patients in a University hospital, after prolonged use of drugs to treat chronic pain and with low adherence to pain scale or guidelines. This is the first report in Colombia.

[Factors associated with the satisfaction of prescribers of blood products in Burkina Faso].

PubMed

Sawadogo, S; Kafando, E; Nébié, K; Ouédraogo, A-S; Ouattara, S; Dahourou, H; Fretz, C; Deneys, V

2017-11-01

The National Blood Transfusion Centre, unique operator of blood transfusion in Burkina Faso is engaged into the quality process according to ISO 9001. Therefore, the assessment of customer satisfaction is a main part of its system. Our study conceives "customer satisfaction" as dependant to the perceived service quality based on SERVQUAL model. To identify factors associated with the satisfaction of blood products prescribers in order to help decision-makers for continuous improvement of services. We conducted a cross-sectional survey among prescribers of blood components in Ouagadougou, between February 27 and April 30, 2015. We used an anonymous self-administered questionnaire, including 13 items associated to the 5 dimensions of SERVQUAL model. The different satisfaction gaps were calculated and linear regression was used to determine statistical associations with a significance level of 5%. The return rate was 94.5% about the 256 questionnaires distributed. A total of 30% of respondents were satisfied to very satisfied. The overall global gap of satisfaction was -5.74. The product delivery time, the efficacy and safety of blood products, the medical and clinical support, the pro-activity of the communication, the management of blood products reservation and the satisfaction of needs in blood products were the factors associated with the prescribers' satisfaction. This first study in blood transfusion services in our context was been useful to assess customer satisfaction and identify the main axes on which targeting priority actions in order to effectively use available resources. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Event coincidence analysis for quantifying statistical interrelationships between event time series. On the role of flood events as triggers of epidemic outbreaks

NASA Astrophysics Data System (ADS)

Donges, J. F.; Schleussner, C.-F.; Siegmund, J. F.; Donner, R. V.

2016-05-01

Studying event time series is a powerful approach for analyzing the dynamics of complex dynamical systems in many fields of science. In this paper, we describe the method of event coincidence analysis to provide a framework for quantifying the strength, directionality and time lag of statistical interrelationships between event series. Event coincidence analysis allows to formulate and test null hypotheses on the origin of the observed interrelationships including tests based on Poisson processes or, more generally, stochastic point processes with a prescribed inter-event time distribution and other higher-order properties. Applying the framework to country-level observational data yields evidence that flood events have acted as triggers of epidemic outbreaks globally since the 1950s. Facing projected future changes in the statistics of climatic extreme events, statistical techniques such as event coincidence analysis will be relevant for investigating the impacts of anthropogenic climate change on human societies and ecosystems worldwide.

Computer-aided auditing of prescription drug claims.

PubMed

Iyengar, Vijay S; Hermiz, Keith B; Natarajan, Ramesh

2014-09-01

We describe a methodology for identifying and ranking candidate audit targets from a database of prescription drug claims. The relevant audit targets may include various entities such as prescribers, patients and pharmacies, who exhibit certain statistical behavior indicative of potential fraud and abuse over the prescription claims during a specified period of interest. Our overall approach is consistent with related work in statistical methods for detection of fraud and abuse, but has a relative emphasis on three specific aspects: first, based on the assessment of domain experts, certain focus areas are selected and data elements pertinent to the audit analysis in each focus area are identified; second, specialized statistical models are developed to characterize the normalized baseline behavior in each focus area; and third, statistical hypothesis testing is used to identify entities that diverge significantly from their expected behavior according to the relevant baseline model. The application of this overall methodology to a prescription claims database from a large health plan is considered in detail.

Combining statistical inference and decisions in ecology

USGS Publications Warehouse

Williams, Perry J.; Hooten, Mevin B.

2016-01-01

Statistical decision theory (SDT) is a sub-field of decision theory that formally incorporates statistical investigation into a decision-theoretic framework to account for uncertainties in a decision problem. SDT provides a unifying analysis of three types of information: statistical results from a data set, knowledge of the consequences of potential choices (i.e., loss), and prior beliefs about a system. SDT links the theoretical development of a large body of statistical methods including point estimation, hypothesis testing, and confidence interval estimation. The theory and application of SDT have mainly been developed and published in the fields of mathematics, statistics, operations research, and other decision sciences, but have had limited exposure in ecology. Thus, we provide an introduction to SDT for ecologists and describe its utility for linking the conventionally separate tasks of statistical investigation and decision making in a single framework. We describe the basic framework of both Bayesian and frequentist SDT, its traditional use in statistics, and discuss its application to decision problems that occur in ecology. We demonstrate SDT with two types of decisions: Bayesian point estimation, and an applied management problem of selecting a prescribed fire rotation for managing a grassland bird species. Central to SDT, and decision theory in general, are loss functions. Thus, we also provide basic guidance and references for constructing loss functions for an SDT problem.

Repeat prescribing of medications: A system‐centred risk management model for primary care organisations

PubMed Central

Price, Julie; Man, Shu Ling; Bartlett, Stephen; Taylor, Kate; Dinwoodie, Mark

2017-01-01

Abstract Rationale, aims and objectives Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care. Methods All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web‐based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses. Results Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1‐33; SD = 7.13). Seven hundred sixty‐seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0‐34; SD = 8.0). Conclusions The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System‐wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally. PMID:28370904

[The effect of prescribing an unsupervised exercise program on the fitness profile of university students participating in an emergency response brigade].

PubMed

León-Rodríguez, Julie C; Cañón-Betancourt, Lorena A

2013-01-01

Determining the effect of a prescribed unsupervised exercise and counseling program on the physical activity and fitness levels of university students volunteering for an emergency response brigade. Forty-two brigade volunteers engaged in a 12-week prescribed non-supervised exercise program. Body weight, body mass index (BMI), percentage body fat, waist circumference, oxygen consumption, flexibility and arms and abdomen strength endurance were assessed before and after performing the exercise program. The other variables measured concerned the level of physical activity during leisure time (days and minutes per week) and/or the use of alternative means of transport. Exercise was prescribed according to international standards. The activities, commitment and health-nutritional recommendations were controlled every two weeks. The study reported a statistically significant increase regarding the following variables: O2 consumption (from 46.41 ± 6.65 ml/Kg/min to 47.70 ± 6.27 ml/Kg/min; p<0.01), increased arm strength endurance (from 11.82 ± 9.97 to 14.74 ± 12.74 repetitions; p<0.01) and an increase in the number of abdominal exercises (crunches) (from 21.16 ± 11.91 to 26.64 ± 17.03 repeats; p<0.01). The real accomplishment regarding commitment by the time of the second measurement concerned 2.54 ± 2.07 days/week and 144.16 ± 238.89 minutes/week of physical activity. These levels were significantly lower than those established at the beginning of the program (4 ± 1.05 days/week and 239.52 ± 73.01 minutes/week; p<0.01). The prescribed unsupervised exercise and counseling program led to increases in oxygen consumption, arm strength endurance and the number of repeat abdominal crunches. Real fulfilment of the proposed activities was lower than planned original commitment.

Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review.

PubMed

Hamilton, Kevin; Davis, Christine; Falk, Jamie; Singer, Alex; Bugden, Shawn

2016-10-01

Background Drug-related problems have been identified as a major contributor to emergency room visits, hospitalizations, and death. The most commonly implicated medications are nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, and anticoagulants. Considering a significant proportion of these harms are preventable, indicators to identify risky prescribing before they lead to harm have been developed. Objective To examine the prevalence and patterns of potentially inappropriate prescriptions (PIPs) in a primary care population who are using high-risk medications. Setting This study was performed within two multi-disciplinary family medicine teaching clinics in Winnipeg, Canada. Method A cross-sectional electronic/paper chart audit was conducted within two multi-disciplinary family medicine teaching clinics to evaluate the prevalence of 13 evidence-based high-risk prescriptions. Patients were included if they were prescribed an oral NSAID, antiplatelet, or an anticoagulant within the 12 month period between June 2012 and June 2013. Main outcome measure The proportion of PIPs associated with an increased bleeding risk for NSAIDs, antiplatelets, and anticoagulants. Results Of the 567 patients included in the review, 198 (35 %) patients had received at least 1 PIP in the past year. The most common PIP was the use of an oral NSAID with one or more GI risk factors without adequate gastro-protection. Only 34 (6 %) of these patients received a full medication review performed by a pharmacist. Although not statistically significant, patients who received a medication review had fewer inappropriate prescriptions (27 % with review, 35 % without). Conclusion Over one-third of the patients who were using high-risk medications were using them potentially inappropriately. Although pharmacists have been shown to reduce the amount of inappropriate prescribing, very few patients using these medications were referred to the pharmacist for a full medication review. These data suggest that there is opportunity for the identification and assessment of these patients when prescribing or dispensing these high-risk medications.

Drug utilization pattern of Chinese herbal medicines in a general hospital in Taiwan.

PubMed

Chen, L C; Wang, B R; Chou, Y C; Tien, J H

2005-09-01

Drug utilization studies are important for the optimization of drug therapy and have received a great attention in recent years. Most of the information on drug use patterns has been derived from studies in modern Western medicines; however, studies regarding the drug utilization of traditional Chinese medicine (CM) are few. The present study was the first clinical research to evaluate the drug utilization patterns of Chinese herbal medicines in a general hospital in Taiwan. Data were collected prospectively from the patients attending the Traditional Medicine Center of Taipei Veteran General Hospital under CM drug treatments. The study was carried out over a period of 1 year, from January 2002 to December 2002. Core drug use indicators, such as the average number of drugs per prescriptions, the dosing frequency of prescriptions, and the most common prescribed CM herbs and formulae were evaluated. The primary diagnosis and the CM drugs prescribed for were also revealed. All data were analyzed by descriptive statistics. A total of 10 737 patients, representing 52 255 CM drugs, were screened during the study period. Regarding the prescriptions, the average number of drugs per prescription was 4.87 and 37.21% of prescriptions were composed by five drugs. Most of prescriptions (91.38%) were prescribed for three times a day. The most often prescribed Chinese herb was Hong-Hwa (5.76%) and the most common Chinese herbal formula was Jia-Wey-Shiau-Yau-San (3.80%). The most frequent main diagnosis was insomnia (15.58%), followed by menopause (5.22%) and constipation (5.09%). The survey revealed the drug use pattern of CMs in a general hospital. The majority of CM prescriptions were composed by 3-6 drugs and often prescribed for three times a day. Generally, the rational drug uses of CM drugs were provided with respect to the various diagnoses. (c) 2005 John Wiley & Sons, Ltd.

Monotherapy of aspirin or warfarin for prevention of ischemic stroke in low-risk atrial fibrillation: A Easter Asian population-based study.

PubMed

Liu, Chieh-Yu; Chen, Hui-Chun

2018-05-02

This study aimed to investigate the effectiveness of monotherapy aspirin and warfarin for stroke prevention in low-risk atrial fibrillation (AF) by using a population-based cohort study in Taiwan. A newly diagnosed low-risk AF patient cohort were identified by using National Health Insurance Research Database (NHIRD) in Taiwan in 2008. The study cohort was observed with a follow-up of 2 years to examine the onset of ischemic stroke (IS) (to 2010). The longitudinal data were analyzed by using generalized estimation equations (GEE). A total of 8,065 newly-diagnosed low-risk AF patients were identified in 2008. 7.4% were prescribed with aspirin and 4.6% were prescribed with warfarin. The GEE results showed that low-risk AF patients with hypertension who received warfarin were associated with a statistically significant 58.4% reduction of IS risk (OR = 0.416, p = 0.024, 95% CI 0.194-0.891). Additionally, low-risk AF patients with hyperlipidemia who received warfarin were associated with a 69.3% reduction of IS risk (OR = 0.307, p = 0.044, 95% CI 0.097-0.969). Warfarin is suggested to be prescribed in preventing ischemic stroke for low-stroke-risk atrial fibrillation patients with hypertension and hyperlipidemia.

Verification of National Weather Service spot forecasts using surface observations

NASA Astrophysics Data System (ADS)

Lammers, Matthew Robert

Software has been developed to evaluate National Weather Service spot forecasts issued to support prescribed burns and early-stage wildfires. Fire management officials request spot forecasts from National Weather Service Weather Forecast Offices to provide detailed guidance as to atmospheric conditions in the vicinity of planned prescribed burns as well as wildfires that do not have incident meteorologists on site. This open source software with online display capabilities is used to examine an extensive set of spot forecasts of maximum temperature, minimum relative humidity, and maximum wind speed from April 2009 through November 2013 nationwide. The forecast values are compared to the closest available surface observations at stations installed primarily for fire weather and aviation applications. The accuracy of the spot forecasts is compared to those available from the National Digital Forecast Database (NDFD). Spot forecasts for selected prescribed burns and wildfires are used to illustrate issues associated with the verification procedures. Cumulative statistics for National Weather Service County Warning Areas and for the nation are presented. Basic error and accuracy metrics for all available spot forecasts and the entire nation indicate that the skill of the spot forecasts is higher than that available from the NDFD, with the greatest improvement for maximum temperature and the least improvement for maximum wind speed.

Use of prescribed burning for managing natural and historic resources in Chickamauga and Chattanooga National Military Park, USA

NASA Astrophysics Data System (ADS)

Faulkner, Jerry L.; Clebsch, Edward E. C.; Sanders, William L.

1989-09-01

The purpose of this study was to provide the National Park Service with quantitative information regarding the effect of fire on fuel loads and pest species such as Lonicera japonica, Ligustrum sinense, and Rhus radicans. Three study areas of ten plots each were located in Chickamauga Battlefield Reservation of the Chickamauga and Chattanooga National Military Park. Fuel weights, aboveground biomass of honeysuckle, and counts of privet and poison ivy were collected both before and after prescribed fire. Additionally, one fourth of each of 14 plots was treated with glyphosate (tradename Roundup) to test for the use of fire as a herbicide pretreatment. This was a randomized block design with subsampling. Prescribed burning did significantly (α = 0.05) reduce fuel loads and the biomass of honeysuckle on burned plots. There was a statistically different response in fuel load reduction between fall and winter burns. Poison ivy significantly increased on burned plots, while privet counts did not vary significantly. Applications of glyphosate negatively impacted all three target species. Honeysuckle appeared to be damaged more readily on untreated plots, while no difference in response was noted on privet. Significantly more poison ivy growing points were killed by herbicide applications on burned plots than on unburned plots.

Structure, composition, and condition of overstory trees

Treesearch

Daniel A. Yaussy; Todd F. Hutchinson; Elaine Kennedy Sutherland

2003-01-01

The structure, composition, and condition of overstory trees in the four study areas prior to prescribed fire treatments are summarized. Stand initiation dates were similar among the study areas (ca. 1885), and coincided with the decline of the charcoal iron industry in southern Ohio. Tree basal area averaged 26.8m²/ha and was not significantly different among...

Bark beetles responses to stand structure and prescribed fire at Black Mountain Experimental Forest, California, USA: 5-year data

Treesearch

C.J. Fettig; S.R. McKelvey

2010-01-01

Highly effective fire suppression and selective harvesting of large-diameter, fire-tolerant tree species, such as ponderosa pine (Pinus ponderosa C. Lawson) and Jeffrey pine (P. jeffreyi Balf.), have resulted in substantial changes to the structure and composition of interior ponderosa pine forests. Mechanical thinning and the...

33 CFR 332.7 - Management.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

33 CFR 332.7 - Management.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

33 CFR 332.7 - Management.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

40 CFR 230.97 - Management.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

33 CFR 332.7 - Management.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

40 CFR 230.97 - Management.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

40 CFR 230.97 - Management.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

40 CFR 230.97 - Management.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., the activity causing the authorized impacts. (b) Sustainability. Compensatory mitigation projects... sustainability. Where active long-term management and maintenance are necessary to ensure long-term sustainability (e.g., prescribed burning, invasive species control, maintenance of water control structures...

Statistic and dosimetric criteria to assess the shift of the prescribed dose for lung radiotherapy plans when integrating point kernel models in medical physics: are we ready?

PubMed

Chaikh, Abdulhamid; Balosso, Jacques

2016-12-01

To apply the statistical bootstrap analysis and dosimetric criteria's to assess the change of prescribed dose (PD) for lung cancer to maintain the same clinical results when using new generations of dose calculation algorithms. Nine lung cancer cases were studied. For each patient, three treatment plans were generated using exactly the same beams arrangements. In plan 1, the dose was calculated using pencil beam convolution (PBC) algorithm turning on heterogeneity correction with modified batho (PBC-MB). In plan 2, the dose was calculated using anisotropic analytical algorithm (AAA) and the same PD, as plan 1. In plan 3, the dose was calculated using AAA with monitor units (MUs) obtained from PBC-MB, as input. The dosimetric criteria's include MUs, delivered dose at isocentre (Diso) and calculated dose to 95% of the target volume (D95). The bootstrap method was used to assess the significance of the dose differences and to accurately estimate the 95% confidence interval (95% CI). Wilcoxon and Spearman's rank tests were used to calculate P values and the correlation coefficient (ρ). Statistically significant for dose difference was found using point kernel model. A good correlation was observed between both algorithms types, with ρ>0.9. Using AAA instead of PBC-MB, an adjustment of the PD in the isocentre is suggested. For a given set of patients, we assessed the need to readjust the PD for lung cancer using dosimetric indices and bootstrap statistical method. Thus, if the goal is to keep on with the same clinical results, the PD for lung tumors has to be adjusted with AAA. According to our simulation we suggest to readjust the PD by 5% and an optimization for beam arrangements to better protect the organs at risks (OARs).

Impact of prescribed fire and other factors on cheatgrass persistence in a Sierra Nevada ponderosa pine forest

USGS Publications Warehouse

Keeley, J.E.; McGinnis, T.W.

2007-01-01

Following the reintroduction of fire Bromus tectorum has invaded the low elevation ponderosa pine forests in parts of Kings Canyon National Park, California. We used prescribed burns, other field manipulations, germination studies, and structural equation modelling, to investigate how fire and other factors affect the persistence of cheatgrass in these forests. Our studies show that altering burning season to coincide with seed maturation is not likely to control cheatgrass because sparse fuel loads generate low fire intensity. Increasing time between prescribed fires may inhibit cheatgrass by increasing surface fuels (both herbaceous and litter), which directly inhibit cheatgrass establishment, and by creating higher intensity fires capable of killing a much greater fraction of the seed bank. Using structural equation modelling, postfire cheatgrass dominance was shown to be most strongly controlled by the prefire cheatgrass seedbank; other factors include soil moisture, fire intensity, soil N, and duration of direct sunlight. Current fire management goals in western conifer forests are focused on restoring historical fire regimes; however, these frequent fire regimes may enhance alien plant invasion in some forest types. Where feasible, fire managers should consider the option of an appropriate compromise between reducing serious fire hazards and exacerbating alien plant invasions. ?? IAWF 2007.

A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital.

PubMed

Li, M; Krishna, M T; Razaq, S; Pillay, D

2014-12-01

To perform a pharmaco-economic analysis of prescribing alternative antibiotics in patients with a diagnostic label of 'penicillin allergy' and assess whether collation of information from a structured history and liaison with the family physician could reduce costs. A prospective pro-forma-based interview of randomly selected in-patients and their family physician was used to assess the validity of the diagnostic label of 'penicillin allergy'. Cost analysis of prescription of alternative antibiotics was performed and compared with first-line agents. 102 patients were assessed and only 40% (n=41) were found to have a history consistent with penicillin hypersensitivity, 40% (n=41) were likely 'not allergic' and 20% (n=20) had 'indeterminate' reactions. Total cost of antibiotics prescribed for patients with penicillin allergy was 1.82-2.58-fold higher than for first-line antibiotics. Obtaining a structured history from the patient and family physician alone can enable an accurate identification of penicillin allergy status. Total acquisition cost of second-line antibiotics is higher than if these patients were prescribed first-line antibiotics. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Perfectionism and athlete burnout in junior elite athletes: the mediating role of coping tendencies.

PubMed

Hill, Andrew P; Hall, Howard K; Appleton, Paul R

2010-07-01

Recent research indicates that some dimensions of perfectionism are positively related to athlete burnout, whereas others are negatively related to athlete burnout. The divergent relationship between these dimensions of perfectionism and athlete burnout may be explained by different coping tendencies. The present investigation examined whether different coping tendencies mediate the relationship between self-oriented and socially prescribed perfectionism and burnout. Two-hundred and six junior elite athletes (M age=15.15 years, SD=1.88 years, range=11-22 years) completed measures of self-oriented and socially prescribed perfectionism, coping tendencies, and athlete burnout. Structural equation modeling indicated that the relationship between dimensions of perfectionism and athlete burnout was mediated by different coping tendencies. Higher levels of socially prescribed perfectionism was related to higher levels of avoidant coping which, in turn, was related to higher levels of athlete burnout. In contrast, higher levels of self-oriented perfectionism was related to higher levels of problem-focused coping and lower levels of avoidant coping which, in turn, was related to lower levels of athlete burnout. The findings suggest that different coping tendencies may underpin the divergent relationship between self-oriented and socially prescribed dimensions of perfectionism and athlete burnout.

Determination of the thermal stress wave propagation in orthotropic hollow cylinder based on classical theory of thermoelasticity

NASA Astrophysics Data System (ADS)

Shahani, Amir Reza; Sharifi Torki, Hamid

2018-01-01

The thermoelasticity problem in a thick-walled orthotropic hollow cylinder is solved analytically using finite Hankel transform and Laplace transform. Time-dependent thermal and mechanical boundary conditions are applied on the inner and the outer surfaces of the cylinder. For solving the energy equation, the temperature itself is considered as boundary condition to be applied on both the inner and the outer surfaces of the orthotropic cylinder. Two different cases are assumed for solving the equation of motion: traction-traction problem (tractions are prescribed on both the inner and the outer surfaces) and traction-displacement (traction is prescribed on the inner surface and displacement is prescribed on the outer surface of the hollow orthotropic cylinder). Due to considering uncoupled theory, after obtaining temperature distribution, the dynamical structural problem is solved and closed-form relations are derived for radial displacement, radial and hoop stress. As a case study, exponentially decaying temperature with respect to time is prescribed on the inner surface of the cylinder and the temperature of the outer surface is considered to be zero. Owing to solving dynamical problem, the stress wave propagation and its reflections were observed after plotting the results in both cases.

The role of paediatric nurses in medication safety prior to the implementation of electronic prescribing: a qualitative case study.

PubMed

Farre, Albert; Heath, Gemma; Shaw, Karen; Jordan, Teresa; Cummins, Carole

2017-04-01

Objectives To explore paediatric nurses' experiences and perspectives of their role in the medication process and how this role is enacted in everyday practice. Methods A qualitative case study on a general surgical ward of a paediatric hospital in England, one year prior to the planned implementation of ePrescribing. Three focus groups and six individual semi-structured interviews were conducted, involving 24 nurses. Focus groups and interviews were audio-recorded, transcribed, anonymized and subjected to thematic analysis. Results Two overarching analytical themes were identified: the centrality of risk management in nurses' role in the medication process and the distributed nature of nurses' medication risk management practices. Nurses' contribution to medication safety was seen as an intrinsic feature of a role that extended beyond just preparing and administering medications as prescribed and placed nurses at the heart of a dynamic set of interactions, practices and situations through which medication risks were managed. These findings also illustrate the collective nature of patient safety. Conclusions Both the recognized and the unrecognized contributions of nurses to the management of medications needs to be considered in the design and implementation of ePrescribing systems.

Statistical plant set estimation using Schroeder-phased multisinusoidal input design

NASA Technical Reports Server (NTRS)

Bayard, D. S.

1992-01-01

A frequency domain method is developed for plant set estimation. The estimation of a plant 'set' rather than a point estimate is required to support many methods of modern robust control design. The approach here is based on using a Schroeder-phased multisinusoid input design which has the special property of placing input energy only at the discrete frequency points used in the computation. A detailed analysis of the statistical properties of the frequency domain estimator is given, leading to exact expressions for the probability distribution of the estimation error, and many important properties. It is shown that, for any nominal parametric plant estimate, one can use these results to construct an overbound on the additive uncertainty to any prescribed statistical confidence. The 'soft' bound thus obtained can be used to replace 'hard' bounds presently used in many robust control analysis and synthesis methods.

Statistical validation of predictive TRANSP simulations of baseline discharges in preparation for extrapolation to JET D-T

NASA Astrophysics Data System (ADS)

Kim, Hyun-Tae; Romanelli, M.; Yuan, X.; Kaye, S.; Sips, A. C. C.; Frassinetti, L.; Buchanan, J.; Contributors, JET

2017-06-01

This paper presents for the first time a statistical validation of predictive TRANSP simulations of plasma temperature using two transport models, GLF23 and TGLF, over a database of 80 baseline H-mode discharges in JET-ILW. While the accuracy of the predicted T e with TRANSP-GLF23 is affected by plasma collisionality, the dependency of predictions on collisionality is less significant when using TRANSP-TGLF, indicating that the latter model has a broader applicability across plasma regimes. TRANSP-TGLF also shows a good matching of predicted T i with experimental measurements allowing for a more accurate prediction of the neutron yields. The impact of input data and assumptions prescribed in the simulations are also investigated in this paper. The statistical validation and the assessment of uncertainty level in predictive TRANSP simulations for JET-ILW-DD will constitute the basis for the extrapolation to JET-ILW-DT experiments.

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

PubMed

Abdel-Qader, Derar H; Harper, Lindsay; Cantrill, Judith A; Tully, Mary P

2010-11-01

Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data. There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.

Acute health care utilization and outcomes for outpatient-treated urinary tract infections in children.

PubMed

Copp, Hillary L; Hanley, Janet; Saigal, Christopher S; Saperston, Kara

2016-08-01

The majority of urinary tract infections (UTIs) in children are treated in the ambulatory setting. The goal of this study is to describe the course of outpatient UTI management, including health services utilization, antibiotic switching (change from empirically prescribed antibiotic to another antibiotic), and antibiotic side effects. Using a large claims database, Truven Health MarketScan Research Database, we analyzed all children younger than 18 years old who had an antibiotic prescribed for an outpatient UTI from 2002 to 2010. We evaluated health services utilization and antibiotic switching in the 21-day period after UTI diagnosis. We compared side effects with rates in patients receiving narrow versus broad-spectrum antibiotic treatment. Chi-square analysis was used for descriptive statistics. We identified 242,819 outpatient, antibiotic-treated, UTI episodes. During the 21-day period after presentation, 26% required more than one visit for UTI management and <1% required hospital admission (Figure). Most children did not have imaging within 21 days of UTI: renal bladder ultrasound in 6%, VCUG in 2.6%, and DMSA in 0.05%. Broad-spectrum antibiotics were empirically prescribed to 34% of patients. Antibiotic switching occurred in only 8% of UTI episodes, indicating that empiric prescription covered the offending uropathogen the majority of the time. Antibiotic side effects occurred in 8% of UTI episodes. The most common side effects were gastrointestinal (∼3% of UTI episodes). All other side effects occurred in <1% of UTI episodes. Although there were statistically significant differences in side effects between broad- and narrow-spectrum antibiotics, these differences were not clinically relevant. Most outpatient UTIs in children do not require more than one healthcare visit, hospital admission, or change in empiric antibiotic therapy. This study supports the fact that pediatric UTIs can be effectively treated in the ambulatory setting. Copyright © 2016. Published by Elsevier Ltd.

How obstetric settings can help address gaps in psychiatric care for pregnant and postpartum women with bipolar disorder.

PubMed

Byatt, Nancy; Cox, Lucille; Moore Simas, Tiffany A; Kini, Nisha; Biebel, Kathleen; Sankaran, Padma; Swartz, Holly A; Weinreb, Linda

2018-03-13

To elucidate (1) the challenges associated with under-recognition of bipolar disorder in obstetric settings, (2) barriers pregnant and postpartum women with bipolar disorder face when trying to access psychiatric care, and (3) how obstetric settings can identify such women and connect them with mental health services. Structured, in-depth interviews were conducted with 25 pregnant and postpartum women recruited from obstetric practices who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II, or not otherwise specified using the Mini International Neuropsychiatric Interview. Quantitative analyses included descriptive statistics. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach. Most participants (n = 19, 79.17%) did not have a clinical diagnosis of bipolar disorder documented in their medical records nor had received referral for treatment during pregnancy (n = 15, 60%). Of participants receiving pharmacotherapy (n = 14, 58.33%), most were treated with an antidepressant alone (n = 10, 71.42%). Most medication was prescribed by an obstetric (n = 4, 28.57%) or primary care provider (n = 7, 50%). Qualitative interviews indicated that participants want their obstetric practices to proactively screen for, discuss and help them obtain mental health treatment. Women face challenges in securing mental health treatment appropriate to their bipolar illness. Obstetric providers provide the bulk of medical care for these women and need supports in place to (1) better recognize bipolar disorder, (2) avoid inappropriate prescribing practices for women with undiagnosed bipolar disorder, and (3) ensure women are referred to specialized treatment when needed.

General Practitioners' Barriers to Prescribe Physical Activity: The Dark Side of the Cluster Effects on the Physical Activity of Their Type 2 Diabetes Patients.

PubMed

Lanhers, Charlotte; Duclos, Martine; Guttmann, Aline; Coudeyre, Emmanuel; Pereira, Bruno; Ouchchane, Lemlih

2015-01-01

To describe barriers to physical activity (PA) in type 2 diabetes patients and their general practitioners (GPs), looking for practitioner's influence on PA practice of their patients. We conducted a cross-sectional study on GPs (n = 48) and their type 2 diabetes patients (n = 369) measuring respectively barriers to prescribe and practice PA using a self-assessment questionnaire: barriers to physical activity in diabetes (BAPAD). Statistical analysis was performed accounting hierarchical data structure. Similar practitioner's patients were considered a cluster sharing common patterns. The higher the patient's BAPAD score, the higher the barriers to PA, the higher the risk to declare practicing no PA (p<0.001), low frequency and low duration of PA (p<0.001). A high patient's BAPAD score was also associated with a higher risk to have HbA1c ≥7% (53 mmol/mol) (p = 0.001). The intra-class correlation coefficient between type 2 diabetes patients and GPs was 34%, indicating a high cluster effect. A high GP's BAPAD score, regarding the PA prescription, is predictive of a high BAPAD score with their patients, regarding their practice (p = 0.03). Type 2 diabetes patients with lower BAPAD score, thus lower barriers to physical activity, have a higher PA level and a better glycemic control. An important and deleterious cluster effect between GPs and their patients is demonstrated: the higher the GP's BAPAD score, the higher the type 2 diabetes patients' BAPAD score. This important cluster effect might designate GPs as a relevant lever for future interventions regarding patient's education towards PA and type 2 diabetes management.

Can commonly prescribed drugs be repurposed for the prevention or treatment of Alzheimer's and other neurodegenerative diseases? Protocol for an observational cohort study in the UK Clinical Practice Research Datalink.

PubMed

Walker, Venexia M; Davies, Neil M; Jones, Tim; Kehoe, Patrick G; Martin, Richard M

2016-12-13

Current treatments for Alzheimer's and other neurodegenerative diseases have only limited effectiveness meaning that there is an urgent need for new medications that could influence disease incidence and progression. We will investigate the potential of a selection of commonly prescribed drugs, as a more efficient and cost-effective method of identifying new drugs for the prevention or treatment of Alzheimer's disease, non-Alzheimer's disease dementias, Parkinson's disease and amyotrophic lateral sclerosis. Our research will focus on drugs used for the treatment of hypertension, hypercholesterolaemia and type 2 diabetes, all of which have previously been identified as potentially cerebroprotective and have variable levels of preclinical evidence that suggest they may have beneficial effects for various aspects of dementia pathology. We will conduct a hypothesis testing observational cohort study using data from the Clinical Practice Research Datalink (CPRD). Our analysis will consider four statistical methods, which have different approaches for modelling confounding. These are multivariable adjusted Cox regression; propensity matched regression; instrumental variable analysis and marginal structural models. We will also use an intention-to-treat analysis, whereby we will define all exposures based on the first prescription observed in the database so that the target parameter is comparable to that estimated by a randomised controlled trial. This protocol has been approved by the CPRD's Independent Scientific Advisory Committee (ISAC). We will publish the results of the study as open-access peer-reviewed publications and disseminate findings through national and international conferences as are appropriate. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Can commonly prescribed drugs be repurposed for the prevention or treatment of Alzheimer's and other neurodegenerative diseases? Protocol for an observational cohort study in the UK Clinical Practice Research Datalink

PubMed Central

Davies, Neil M; Jones, Tim; Kehoe, Patrick G; Martin, Richard M

2016-01-01

Introduction Current treatments for Alzheimer's and other neurodegenerative diseases have only limited effectiveness meaning that there is an urgent need for new medications that could influence disease incidence and progression. We will investigate the potential of a selection of commonly prescribed drugs, as a more efficient and cost-effective method of identifying new drugs for the prevention or treatment of Alzheimer's disease, non-Alzheimer's disease dementias, Parkinson's disease and amyotrophic lateral sclerosis. Our research will focus on drugs used for the treatment of hypertension, hypercholesterolaemia and type 2 diabetes, all of which have previously been identified as potentially cerebroprotective and have variable levels of preclinical evidence that suggest they may have beneficial effects for various aspects of dementia pathology. Methods and analysis We will conduct a hypothesis testing observational cohort study using data from the Clinical Practice Research Datalink (CPRD). Our analysis will consider four statistical methods, which have different approaches for modelling confounding. These are multivariable adjusted Cox regression; propensity matched regression; instrumental variable analysis and marginal structural models. We will also use an intention-to-treat analysis, whereby we will define all exposures based on the first prescription observed in the database so that the target parameter is comparable to that estimated by a randomised controlled trial. Ethics and dissemination This protocol has been approved by the CPRD's Independent Scientific Advisory Committee (ISAC). We will publish the results of the study as open-access peer-reviewed publications and disseminate findings through national and international conferences as are appropriate. PMID:27965247

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study.

PubMed

Rochefort, Christian M; Morlec, Julia; Tamblyn, Robyn M

2012-02-29

Thiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices. A comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data. We identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach. Physicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

Individually prescribed diet is fundamental to optimize nutritional treatment in geriatric patients.

PubMed

Hedman, S; Nydahl, M; Faxén-Irving, G

2016-06-01

Malnutrition is a well-recognized problem in geriatric patients. Individually prescribed diet is fundamental to optimize nutritional treatment in geriatric patients. The objective of this study was to investigate routines regarding dietary prescriptions and monitoring of food intake in geriatric patients and to see how well the prescribed diet conforms to the patients' nutritional status and ability to eat. A further aim was to identify the most common reasons and factors interacting with patients not finishing a complete meal. This study combines two methods using both qualitative and quantitative analysis. Patients (n = 43; 82.5 ± 7.5 yrs; 60% females) at four geriatric wards performed a two-day dietary record, assisted by a dietician. Nurses and assistant nurses at each ward participated in a semi-structured interview regarding prescription of diets and portion size for the patients. The prescribed diet differed significantly (P < 0.01) from a diet based upon the patient's nutritional status and ability to eat. Only 30% of the patients were prescribed an energy-enriched diet in contrast to 60% that was in need of it. The most common reason for not finishing the meal was lack of appetite. Diet prescription for the patient was based upon information about eating difficulties identified in the Mini Nutritional Assessment-Short Form (MNA-SF) at admission and the type of diet that was prescribed on a previous ward. Monitoring of the patients' food intake was described as a continuous process discussed daily between the staff. Patients' nutritional status and to what extent they were able to eat a complete meal was not routinely considered when prescribing food and monitoring food intake in this study. By making use of this information the diet could be tailored to the patients' needs, thereby improving their nutritional treatment. Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Short-term effects of prescribed burning on litterfall biomass in mixed stands of Pinus nigra and Pinus pinaster and pure stands of Pinus nigra in the Cuenca Mountains (Central-Eastern Spain).

PubMed

Espinosa, J; Madrigal, J; De La Cruz, A C; Guijarro, M; Jimenez, E; Hernando, C

2018-03-15

Fire severity, defined as the magnitude of fire effects in an ecosystem, is a key factor to consider in planning management strategies for protecting forests against fire. Although prescribed burning has been used as a fuel reduction tool in forest ecosystems, it is quite limited in the Mediterranean region. Furthermore, little is known about how tree crowns are affected by prescribed underburning aimed at reducing fire severity in conifer stands. As part of an ongoing study to assess the effects of prescribed burning on the tree canopy, litterfall is currently being monitored in a network of experimental plots located in mixed (Pinus nigra and Pinus pinaster) and pure (P. nigra) conifer stands in the Cuenca Mountains (Castilla La Mancha, Spain). A total of 12 study plots (30m×30m) were established in a completely randomized experimental design to determine the effect of burning, with 2 treatments: no burning (control) and burning (i.e. with three replicate plots for each treatment and site). Burning was conducted in May 2016. In each plot, 8 litterfall collectors were installed at regular intervals, according to international protocols (ICP Forests), and all biomass falling into the collectors is being monitored monthly. The specific objective of this study is to assess how prescribed burning affects the rate of generation of foliar and non-foliar litterfall biomass due to the fire. In addition, the Leaf Area Index was estimated before burning and one year later to verify possible changes in the structure of the stands. This information could be used to help minimize the negative impacts of prescribed underburning on litterfall. To our knowledge, this study represents the first attempt to evaluate the effect of prescribed burning on litterfall biomass in Europe. Copyright © 2017 Elsevier B.V. All rights reserved.

The Knowledge, Attitude and the Perception of Prescribers on the Rational Use of Antibiotics and the Need for an Antibiotic Policy–A Cross Sectional Survey in a Tertiary Care Hospital

PubMed Central

Remesh, Ambili; Gayathri, A.M; Singh, Rohit; Retnavally, K.G.

2013-01-01

Background: Antibiotics are prescribed frequently and there is always an overuse with a risk of resistance and increasing costs. Rational drug prescribing is essential for minimizing the health care costs and for reducing the resistance. The implementation of a strict antibiotic policy by all the health care institutes is being made mandatory nowadays. An improving awareness among the prescribers which can be created through educational interventions, can promote the rational use of antibiotics. Hence, we considered it worthwhile to study the knowledge, attitude and the perception of the practitioners towards a rational antibiotic use. Materials and Methods: All the registered practitioners who were working in the hospital setting and were willing to give written informed consents, were enrolled in the study. All the participants who were enrolled in the study during a one month period, had to fill up a predesigned, structured and validated questionnaire which was used to assess the knowledge, attitude and the perception among physicians towards the rational use of antibiotics. Results: About 65% of the participants who provided complete information in the questionnaire, were included in analysis. Among them, more than 50 % agreed on the existence of an essential drug list, on the knowledge about new antibiotics and on prescribing antibiotics rationally and on the interpretation of the culture and the sensitivity results. A majority strongly agreed that they ensured that their patients completed the course, that they provided counselling and that they took special interest in the proper use of antibiotics. There was a consensus on the overuse, issues of resistance, and on the input from fellow colleagues. Conclusion: The participants in our study had knowledge about the rational use of antibiotics, an attitude to prescribe drugs as per the essential drug list and a perception that antibiotics were being overused and that rational drug prescribing had an important role in the antibiotic resistance. PMID:23730644

Hospital staff views of prescribing and discharge communication before and after electronic prescribing system implementation.

PubMed

Mills, Pamela Ruth; Weidmann, Anita Elaine; Stewart, Derek

2017-12-01

Background Electronic prescribing system implementation is recommended to improve patient safety and general practitioner's discharge information communication. There is a paucity of information about hospital staff perspectives before and after system implementation. Objective To explore hospital staff views regarding prescribing and discharge communication systems before and after hospital electronic prescribing and medicines administration (HEPMA) system implementation. Setting A 560 bed United Kingdom district general hospital. Methods Semi-structured face-to-face qualitative interviews with a purposive sample of hospital staff involved in the prescribing and discharge communication process. Interviews transcribed verbatim and coded using the Framework Approach. Behavioural aspects mapped to Theoretical Domains Framework (TDF) to highlight associated behavioural change determinants. Main outcome measure Staff perceptions before and after implementation. Results Nineteen hospital staff (consultant doctors, junior doctors, pharmacists and advanced nurse practitioners) participated before and after implementation. Pre-implementation main themes were inpatient chart and discharge letter design and discharge communication process with issues of illegible and inaccurate information. Improved safety was anticipated after implementation. Post-implementation themes were improved inpatient chart clarity and discharge letter quality. TDF domains relevant to staff behavioural determinants preimplementation were knowledge (task or environment); skills (competence); social/professional roles and identity; beliefs about capabilities; environmental context and resources (including incidents). An additional two were relevant post-implementation: social influences and behavioural regulation (including self-monitoring). Participants described challenges and patient safety concerns pre-implementation which were mostly resolved post-implementation. Conclusion HEPMA implementation produced perceptions of patient safety improvement. TDF use enabled behaviour change analysis due to implementation, for example, staff adoption of behaviours to ensure general practitioners receive good quality discharge information.

Enhancing the quality of antibiotic prescribing in Primary Care: Qualitative evaluation of a blended learning intervention

PubMed Central

2010-01-01

Background The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial. Methods Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis. Results The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data. Conclusion Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program. Trial registration Current Controlled Trials ISRCTN63355948 PMID:20459655

Experiences of nurses as postgraduate students of pharmacology and therapeutics: a multiple case narrative study.

PubMed

Lim, Anecita Gigi; North, Nicola; Shaw, John

2014-06-01

Pharmacology and therapeutics are essential components of educational programmes in prescribing, yet little is known about students' experiences in studying these subjects for a prescribing role. To investigate the views and experiences of nurses as postgraduate students who were studying pharmacology and therapeutics in preparation for a prescribing role. Qualitative study using a multiple case narrative approach. The participants were undertaking or had recently completed a Master's degree programme; they worked in a range of clinical areas and services in the Auckland region. Twenty nurses, with advanced clinical backgrounds and experience engaged in postgraduate studies in pharmacology and therapeutics. A semi-structured interview of approximately 1h was undertaken with each participant. Transcripts were analysed within and across cases using Narralizer software to support thematic analysis. There were four broad thematic areas. In the first, 'prescribing in the context of advanced nursing practice', participants reflected on why prescribing authority was important to them. In the second theme, 'adequacy of prior pharmacology knowledge' they discussed the relative lack of pharmacology in their undergraduate programmes and in nursing practice. In the third, 'drawing on clinical experience in acquiring pharmacology knowledge', participants discussed how, as they grappled with new pharmacological science, they drew on clinical experience which facilitated their learning. In the fourth theme, 'benefits of increased pharmacology knowledge' they discussed how their studies improved their interactions with patients, medical colleagues and as members of multi-disciplinary teams. All nurses viewed their studies in pharmacology as fundamental to their roles as prescribers, through knowledge development and an increase in confidence. Although pharmacology theory was new to many participants, their learning was facilitated because they were able to reflect on previous clinical experience and apply this to theory. Copyright © 2014 Elsevier Ltd. All rights reserved.

Non-prescribed antimicrobial use and associated factors among customers in drug retail outlet in Central Zone of Tigray, northern Ethiopia: a cross-sectional study.

PubMed

Gebrekirstos, Negash Hadera; Workneh, Birhanu Demeke; Gebregiorgis, Yosef Sibhatu; Misgina, Kebede Haile; Weldehaweria, Negassie Berhe; Weldu, Meresa Gebremedhin; Belay, Hailay Siyum

2017-01-01

Non-prescribed antimicrobial use and their resistance are among the main public health problems, worldwide. In Ethiopia, particularly in the northern part, the magnitude of non-prescribed antimicrobial use and its major determinants is not yet well known. Thus, this study was done to assess the magnitude of non-prescribed anti-microbial use and associated factors among customers in drug retail outlet in Central Zone, Tigray, Ethiopia. A drug retail outlet based cross-sectional study was conducted among adults aged 18 years and above. A multistage sampling procedure was used to select study participants. Data were collected using a structured questionnaire by druggists under the supervision of pharmacists. Data were entered into EpiInfo software version 3.5.4. Binary logistic regression was used to identify independently associated variables in bivariate and multivariable analyses using SPSS version 21. Odds Ratios with 95% confidence intervals were estimated. From 829 study samples, a total of 780 respondents participated in this study with a response rate of 94.1%. Of 367 respondents who received non-prescribed antimicrobial, 249 (67.8%), 121 (33%), and 94 (25.6%) of them were males, secondary school and paid employed respectively. The magnitude of non-prescribed antimicrobial use was 47.1% (95% CI: 43.8, 50.5). The factors which were independently associated with non-prescribed antimicrobial use were male sex [AOR = 1.72, 95% CI = 1.21, 2.44], seeking modern health care in private/Non-Governmental Organization (NGO) [AOR =0.47, 95% CI; 0.23, 0.98], moderate waiting time in health care facilities [AOR = 1.92, 95% CI; 1.20, 3.09], delayed waiting time in health care facilities [AOR = 1.56, 95% CI; 1.03, 2.38], ever received antimicrobial [AOR = 3.51, 95% CI; 2.45, 5.02], and frequency of purchasing non-prescribed antimicrobial (1-3 times and 4 times, [AOR = 2.04, 95% CI; 1.36, 3.06] and [AOR = 2.66, 95% CI; 1.24, 5.68] respectively). The magnitude of non-prescribed antimicrobial use was high. Familiarizing with health care utilization and delayed waiting time in health care facilities were the very important factors independently associated with non-prescribed antimicrobial use. Emphasis should be given to community education through involvement of the private health sector and health care providers. Regulation and policy enforcement are also necessary to promote the rational use of antimicrobial.

48 CFR 552.238-71 - Submission and Distribution of Authorized FSS Schedule Pricelists.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Multiple Award Schedule electronic data base. (d) The Contractor shall make all of the distributions... electronic submission with the award notification. Some structured data entry in a prescribed format may be...

48 CFR 552.238-71 - Submission and Distribution of Authorized FSS Schedule Pricelists.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Multiple Award Schedule electronic data base. (d) The Contractor shall make all of the distributions... electronic submission with the award notification. Some structured data entry in a prescribed format may be...

48 CFR 552.238-71 - Submission and Distribution of Authorized FSS Schedule Pricelists.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Multiple Award Schedule electronic data base. (d) The Contractor shall make all of the distributions... electronic submission with the award notification. Some structured data entry in a prescribed format may be...

48 CFR 552.238-71 - Submission and Distribution of Authorized FSS Schedule Pricelists.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Multiple Award Schedule electronic data base. (d) The Contractor shall make all of the distributions... electronic submission with the award notification. Some structured data entry in a prescribed format may be...

48 CFR 552.238-71 - Submission and Distribution of Authorized FSS Schedule Pricelists.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Multiple Award Schedule electronic data base. (d) The Contractor shall make all of the distributions... electronic submission with the award notification. Some structured data entry in a prescribed format may be...

Low order H∞ optimal control for ACFA blended wing body aircraft

NASA Astrophysics Data System (ADS)

Haniš, T.; Kucera, V.; Hromčík, M.

2013-12-01

Advanced nonconvex nonsmooth optimization techniques for fixed-order H∞ robust control are proposed in this paper for design of flight control systems (FCS) with prescribed structure. Compared to classical techniques - tuning of and successive closures of particular single-input single-output (SISO) loops like dampers, attitude stabilizers, etc. - all loops are designed simultaneously by means of quite intuitive weighting filters selection. In contrast to standard optimization techniques, though (H2, H∞ optimization), the resulting controller respects the prescribed structure in terms of engaged channels and orders (e. g., proportional (P), proportional-integral (PI), and proportional-integralderivative (PID) controllers). In addition, robustness with regard to multimodel uncertainty is also addressed which is of most importance for aerospace applications as well. Such a way, robust controllers for various Mach numbers, altitudes, or mass cases can be obtained directly, based only on particular mathematical models for respective combinations of the §ight parameters.

8 CFR 499.1 - Prescribed forms.

Code of Federal Regulations, 2011 CFR

2011-01-01

... shown or a subsequent edition date. Form No. Edition date Title and description M-288 12-30-87 United States History 1600-1987, Level II. M-289 12-31-87 United States History 1600-1987, Level I. M-290 01-01-90 U.S. Government Structure, Level II. M-291 12-31-87 U.S. Government Structure, Level I. M-302 03...

8 CFR 499.1 - Prescribed forms.

Code of Federal Regulations, 2010 CFR

2010-01-01

... shown or a subsequent edition date. Form No. Edition date Title and description M-288 12-30-87 United States History 1600-1987, Level II. M-289 12-31-87 United States History 1600-1987, Level I. M-290 01-01-90 U.S. Government Structure, Level II. M-291 12-31-87 U.S. Government Structure, Level I. M-302 03...

Understory vegetation response to thinning and burning restoration treatments in dry conifer forests of the eastern Cascades, USA

Treesearch

Erich Kyle Dodson; David W. Peterson; Richy J. Harrod

2008-01-01

Restoration/fuel reduction treatments are being widely used in fire-prone forests to modify stand structure, reduce risks of severe wildfire, and increase ecosystem resilience to natural disturbances. These treatments are designed to manipulate stand structure and fuels, but may also affect understory vegetation and biodiversity. In this study, we describe prescribed...

The influence of fire on lepidopteran abundance and community structure in forested habitats of eastern Texas

Treesearch

D. Craig Rudolph; Charles A. Ely

2000-01-01

Transect surveys were used to examine the influence of fire on lepidopteran communities (Papilionoidea and Hesperioidea) in forested habitats in eastern Texas. Lepidopteran abundance was greater in pine forests where prescribed fire maintained an open mid- and understory compared to forests where fire had less impact on forest structure. Ahundance of nectar sources...

Cost efficiency of intranasal corticosteroid prescribing patterns in the management of allergic rhinitis.

PubMed

Reissman, Debi; Price, Tom; Leibman, Christopher W

2004-01-01

Effective treatment of seasonal or perennial allergic rhinitis often requires use of topical intranasal corticosteroids (INSs). Despite differences in recommended starting dosages, the 4 leading INSs by market share are packaged in bottles containing 120 metered-dose sprays. To determine the relative prescribed dosages of the leading INSs and compare economic differences resulting from these prescribing behaviors. The IMS National Disease and Therapeutic Index (NDTI) was used to identify prescribing habits for the 4 leading INSs: fluticasone propionate nasal spray (FPNS), mometasone furoate aqueous nasal spray (MFNS), triamcinolone acetonide aqueous nasal spray (TANS), and budesonide aqueous nasal spray (BANS). The NDTI uses a national, randomly drawn, 2-stage stratified clustersampling methodology. Physicians are sampled during the first stage, with 2 workdays per month subsampled from each physician in the second stage. Each physician reports on all patient contacts during the 2 consecutive days, offering a continuing compilation of statistical information about patterns and treatment of disease encountered by office-based physicians. In a given month, the NDTI reports on 1180 unique physicians. From January 1, 2002, to December 31, 2002, 58% of prescriptions for FPNS were for 4 sprays daily with 37% for 2 sprays daily, MFNS: 44% for 4 sprays and 52% for 2, TANS: 65% for 4 sprays and 31% for 2, and BANS: 29% for 4 sprays and 68% for 2. These equated to mean prescribed daily dosages of 3.47 sprays per day for FPNS, 3.33 for MFNS, 3.50 for TANS, and 2.73 for BANS. Because each INS is packaged in a bottle with 120 metered-dose sprays, the differences in dosage offer varying days of supply per unit filled. BANS offered the most days of treatment (44 days), followed by MFNS (38 days) and FPNS and TANS (means of 35 and 34 days, respectively) per single prescription filled. Cost per day of treatment was calculated by multiplying the prescribed dosage with the average wholesale price of the products. BANS had the lowest cost per day of treatment at US dollars 1.54, with each other INS costing at least an additional US dollars 0.26 daily (MFNS US dollars 1.80; FPNS US dollars 1.88; TANS US dollars 1.97). Based on physician prescribing patterns of INSs from the NDTI database, BANS offers more days of treatment at a lower cost per day than other leading INSs.

"I'm Dr Jekyll and Mr Hyde": are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study.

PubMed

Strandberg, Eva Lena; Brorsson, Annika; Hagstam, Charlotta; Troein, Margareta; Hedin, Katarina

2013-09-01

To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. Primary health care in two counties in southern Sweden. Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. Exploration of categories, determination of themes, construction of models. The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.

Optimizing carbapenem use through a national quality improvement programme.

PubMed

Robson, Siân E; Cockburn, Alison; Sneddon, Jacqueline; Mohana, Abdulrhman; Bennie, Marion; Mullen, Alexander B; Malcolm, William; Armstrong, Jennifer; Patton, Andrea; Seaton, Ronald Andrew

2018-05-24

Concern about increasing carbapenem and piperacillin/tazobactam use led the Scottish Antimicrobial Prescribing Group (SAPG) to develop national guidance on optimal use of these agents, and to implement a quality improvement programme to assess the impact of guidance on practice. To evaluate how SAPG guidance had been implemented by health boards, assess how this translated into clinical practice, and investigate clinicians' views and behaviours about prescribing carbapenems and alternative agents. Local implementation of SAPG guidance was assessed using an online survey. A bespoke point prevalence survey was used to evaluate prescribing. Clinicians' experience of using carbapenems and alternatives was examined through semi-structured interviews. National prescribing data were analysed to assess the impact of the programme. There were greater local restrictions for carbapenems than for piperacillin/tazobactam. Laboratory result suppression was inconsistent between boards and carbapenem-sparing antibiotics were not widely available. Compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antibiotics. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antibiotics decreased during the course of the programme. A multifaceted quality improvement programme was used to gather intelligence, promote behaviour change, and focus interventions on the use of carbapenems and piperacillin/tazobactam. Use of these antimicrobials decreased during the programme-a trend not seen elsewhere in Europe. The programme could be generalized to other antimicrobials.

Harassment of working women in the public health sector of Abbottabad in socio-legal perspective.

PubMed

Jabeen, Musarrat; Naeem, Zeeshan Muhammad; Umar, Muhammad; Yameen, Muhammad Arfat; Azhar, Saira

2017-01-01

To investigate the efficacy and impact of Protection Against Harassment of Women at Workplace Act 2010 in the public health sector in its socio-legal perspective. This cross-sectional study was conducted from July to December 2014 in Abbottabad, Pakistan, and comprised subjects selected from 53 basic health units managed by the government. SPSS 20 was used for statistical analysis. Of the 450 questionnaires, 430(96.6%) were returned duly filled. Overall, 40% male (120 respondents) and 26% female (34 respondents) knew about the Act. Besides, 39% males (117 respondents) and 63% females (82 respondents) appeared unsatisfied with the complaint mechanism prescribed in the Act; all the respondents established that no case had been registered after the introduction of the Act. Overall, 31% males (93 respondents) and 57% females (74 respondents) thought that without the health governance commitment and social support structure the Act could not work. The Protection Against Harassment of Women at Workplace Act 2010 was considered ineffective by the respondents who were concerned about the lack of social support system for the Act.

Characterizing relative humidity with respect to ice in midlatitude cirrus clouds as a function of atmospheric state

NASA Astrophysics Data System (ADS)

Dzambo, Andrew M.; Turner, David D.

2016-10-01

Midlatitude cirrus cloud macrophysical and microphysical properties have been shown in previous studies to vary seasonally and in various large-scale dynamical regimes, but relative humidity with respect to ice (RHI) within cirrus clouds has not been studied extensively in this context. Using a combination of radiosonde and millimeter-wavelength cloud radar data, we identify 1076 cirrus clouds spanning a 7 year period from 2004 to 2011. These data are separated into five classes using a previously published algorithm that is based largely on synoptic conditions. Using these data and classification scheme, we find that RHI in cirrus clouds varies seasonally. Variations in cirrus cloud RHI exist within the prescribed classifications; however, most of the variations are within the measurement uncertainty. Additionally, with the exception of nonsummer class cirrus, these variations are not statistically significant. We also find that cirrus cloud occurrence is not necessarily correlated with higher observed values of RHI. The structure of RHI in cirrus clouds varies more in thicker clouds, which follows previous studies showing that macrophysical and microphysical variability increases in thicker cirrus clouds.

14 CFR 25.343 - Design fuel and oil loads.

Code of Federal Regulations, 2010 CFR

2010-01-01

... conditions of § 25.341(a) but assuming 85% of the design velocities prescribed in § 25.341(a)(4). (2) Fatigue evaluation of the structure must account for any increase in operating stresses resulting from the design...

48 CFR 252.246-7004 - Safety of Facilities, Infrastructure, and Equipment for Military Operations.

Code of Federal Regulations, 2013 CFR

2013-10-01

..., Infrastructure, and Equipment for Military Operations. As prescribed in 246.270-4, use the following clause... contract comply with Unified Facilities Criteria (UFC) 1-200-01 for— (1) Fire protection; (2) Structural...

48 CFR 252.246-7004 - Safety of Facilities, Infrastructure, and Equipment for Military Operations.

Code of Federal Regulations, 2012 CFR

2012-10-01

..., Infrastructure, and Equipment for Military Operations. As prescribed in 246.270-4, use the following clause... contract comply with Unified Facilities Criteria (UFC) 1-200-01 for— (1) Fire protection; (2) Structural...

48 CFR 252.246-7004 - Safety of Facilities, Infrastructure, and Equipment for Military Operations.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., Infrastructure, and Equipment for Military Operations. As prescribed in 246.270-4, use the following clause... contract comply with Unified Facilities Criteria (UFC) 1-200-01 for— (1) Fire protection; (2) Structural...

Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit.

PubMed

Nzegwu, Nneka I; Rychalsky, Michelle R; Nallu, Loren A; Song, Xuemei; Deng, Yanhong; Natusch, Amber M; Baltimore, Robert S; Paci, George R; Bizzarro, Matthew J

2017-10-01

OBJECTIVE To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP). DESIGN Quasi-experimental, interrupted time-series study. SETTING A 54-bed, level IV NICU in a regional academic and tertiary referral center. PATIENTS AND PARTICIPANTS All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion. INTERVENTION Implementation of a NICU-specific ASP beginning July 2012. METHODS We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance. RESULTS Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time. CONCLUSIONS Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices. Infect Control Hosp Epidemiol 2017;38:1137-1143.

The Antimicrobial Treatment Strategies (MIKSTRA) program: a 5-year follow-up of infection-specific antibiotic use in primary health care and the effect of implementation of treatment guidelines.

PubMed

Rautakorpi, Ulla-Maija; Huikko, Solja; Honkanen, Pekka; Klaukka, Timo; Makela, Marjukka; Palva, Erkki; Roine, Risto; Sarkkinen, Hannu; Varonen, Helena; Huovinen, Pentti

2006-05-01

A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines. The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information. The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up. Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Cost-effectiveness of dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation: a Canadian payer perspective.

PubMed

Sorensen, S V; Kansal, A R; Connolly, S; Peng, S; Linnehan, J; Bradley-Kennedy, C; Plumb, J M

2011-05-01

Oral dabigatran etexilate is indicated for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF) in whom anticoagulation is appropriate. Based on the RE-LY study we investigated the cost-effectiveness of Health Canada approved dabigatran etexilate dosing (150 mg bid for patients <80 years, 110 mg bid for patients ≥80 years) versus warfarin and "real-world" prescribing (i.e. warfarin, aspirin, or no treatment in a cohort of warfarin-eligible patients) from a Canadian payer perspective. A Markov model simulated AF patients at moderate to high risk of stroke while tracking clinical events [primary and recurrent ischaemic strokes, systemic embolism, transient ischaemic attack, haemorrhage (intracranial, extracranial, and minor), acute myocardial infarction and death] and resulting functional disability. Acute event costs and resulting long-term follow-up costs incurred by disabled stroke survivors were based on a Canadian prospective study, published literature, and national statistics. Clinical events, summarized as events per 100 patient-years, quality-adjusted life years (QALYs), total costs, and incremental cost effectiveness ratios (ICER) were calculated. Over a lifetime, dabigatran etexilate treated patients experienced fewer intracranial haemorrhages (0.49 dabigatran etexilate vs. 1.13 warfarin vs. 1.05 "real-world" prescribing) and fewer ischaemic strokes (4.40 dabigatran etexilate vs. 4.66 warfarin vs. 5.16 "real-world" prescribing) per 100 patient-years. The ICER of dabigatran etexilate was $10,440/QALY versus warfarin and $3,962/QALY versus "real-world" prescribing. This study demonstrates that dabigatran etexilate is a highly cost-effective alternative to current care for the prevention of stroke and systemic embolism among Canadian AF patients.

Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections.

PubMed

Llor, Carl; Bjerrum, Lars; Molero, José M; Moragas, Ana; González López-Valcárcel, Beatriz; Monedero, M José; Gómez, Manuel; Cid, Marina; Alcántara, Juan de Dios; Cots, Josep M; Ribas, Joana M; García, Guillermo; Ortega, Jesús; Pineda, Vicenta; Guerra, Gloria; Munuera, Susana

2018-04-27

Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs). The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001). This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.

Drug utilisation profile in the neonatal unit of a university hospital: a prospective observational study in Brazil.

PubMed

Gonçalves, Adriana Cristina de Souza; Reis, Adriano Max Moreira; Gusmão, Ana Carolina Marçal; Bouzada, Maria Cândida Ferrarez

2015-08-01

Advances in neonatology have contributed to changes in the drug utilisation profile in neonates, both in the number of drugs and the pharmacotherapeutic groups. To analyse drug use in the neonatal care unit of a teaching hospital in Brazil and to evaluate the associations among perinatal, clinical care and drug use data. The neonatal care unit of a teaching hospital in Brazil. A prospective observational study was conducted. Perinatal, clinical care and pharmacotherapy data were collected from the patients' medical records. Labelling information regarding neonatal use was analysed for prescribed drugs. The data were analysed using univariate descriptive statistics and quasi-Poisson regression. Frequency of drug use by gestational age. The study included 187 patients; 157 (84.0 %) received drugs. The mean gestational age was 35.8 weeks. The mean number of drugs prescribed per patient was 6.4. The number of drugs used was inversely correlated to gestational age and birth weight. The most commonly prescribed drugs belonged to the following anatomical therapeutic chemical groups: nervous system drugs, anti-infectives for systemic use, and alimentary tract and metabolism drugs. Information regarding neonatal use was given in the labelling of only 20.5 % of the prescribed drugs. Of these, only 9.5 % had information specific for preterm infants. Drug administration to neonates is frequently and inversely correlated to gestational age and birth weight. Neonates are exposed to different therapeutic classes, reflecting scientific advances in neonatology. In Brazil, the percentage of drugs with neonate-specific labelling information is low. Consequently, there is an evident need for efforts to guarantee effective and safe pharmacotherapy for neonates.

Coadministration of Co-trimoxazole With Sulfonylureas: Hypoglycemia Events and Pattern of Use

PubMed Central

Holmes, Holly M.; Kuo, Yong-Fang; Raji, Mukaila A.; Goodwin, James S.

2015-01-01

Background. Coadministration of co-trimoxazole with sulfonylureas is reported to increase the risk of hypoglycemia. Methods. We identified a cohort of Medicare beneficiaries aged 66 years or older who took glyburide or glipizide for diabetes from a 5% national sample of Medicare Part D claims data in 2008 (n = 34,239). We tracked each participant’s claims during 2008–2010 for a co-trimoxazole prescription and subsequent emergency room visits for hypoglycemia. Descriptive statistics and logistic regression modeling were used to evaluate hypoglycemia-related emergency room visits after coadministration of co-trimoxazole with sulfonylureas and its utilization patterns in older adults with diabetes. Results. Sulfonylureas users prescribed co-trimoxazole had a significant higher risk of emergency room visits for hypoglycemia, compared with those prescribed noninteracting antibiotics (odds ratio = 3.89, 95% confidence interval = 2.29–6.60 for glipizide and odds ratio = 3.78, 95% confidence interval = 1.81–7.90 for glyburide with co-trimoxazole, using amoxicillin as the reference). Co-trimoxazole was prescribed to 16.9% of those taking glyburide or glipizide during 2008–2010, varying from 4.0% to 35.9% across U.S. hospital referral regions. Patients with polypharmacy and with more prescribers were more likely to receive co-trimoxazole. Patients with an identifiable primary care physician had 20% lower odds of receiving a co-trimoxazole prescription. Hospital referral regions with more PCPs had lower rates of coadministration of the two drugs (r = −.26, p < 0.001). Conclusions. Coadministration of co-trimoxazole with sulfonylureas is associated with increased risk of hypoglycemia, compared with noninteracting antibiotics. Such coadministration is prevalent among older diabetic patients in the United States, especially in patients without an identifiable primary care physician. PMID:24858839

Homeopathic treatment of premenstrual syndrome: a case series.

PubMed

Danno, Karine; Colas, Aurélie; Terzan, Laurence; Bordet, Marie-France

2013-01-01

Observational, prospective study to describe the homeopathic management of premenstrual syndrome (PMS) by a group of French physicians. Women with PMS for >3 months were prescribed individualized homeopathic treatment. The intensity of 10 clinical symptoms of PMS was scored individually at inclusion and at a 3-6 month follow-up visit: absent = 0, mild = 1, moderate = 2, severe = 3. Total symptom score (range: 0-30) was calculated and compared for each patient at inclusion and at follow-up. PMS impact on daily activities (quality of life, QoL) was compared at inclusion and follow-up as: none, mild, moderate, severe, very severe. Twenty-three women were prescribed homeopathic treatment only (mean age: 39.7 years). Folliculinum (87%) was the most frequently prescribed homeopathic medicine followed by Lachesis mutus (52.2%). The most common PMS symptoms (moderate or severe) at inclusion were: irritability, aggression and tension (87%), mastodynia (78.2%) and weight gain and abdominal bloating (73.9%); and the most common symptoms at follow-up were: irritability, aggression and tension (39.1%), weight gain and abdominal bloating (26.1%) and mastodynia (17.4%). Mean global score for symptom intensity was 13.7 at inclusion and 6.3 at follow-up. The mean decrease in score (7.4) was statistically significant (p < 0.0001). Twenty-one women reported that their QoL also improved significantly (91.3%; p < 0.0001). Homeopathic treatment was well tolerated and seemed to have a positive impact on PMS symptoms. Folliculinum was the most frequent homeopathic medicine prescribed. There appears to be scope for a properly designed, randomized, placebo-controlled trial to investigate the efficacy of individual homeopathic medicines in PMS. Copyright © 2012 The Faculty of Homeopathy. Published by Elsevier Ltd. All rights reserved.

Pharmacotherapy of Bipolar Affective Disorder: A Hospital based Study from Sub Himalayan Valley of Nepal

PubMed Central

Sathian, Brijesh; Chakraborty, Prasanta Kumar; Banerjee, Indraneel; Roy, Bedanta; Jauhari, Akhilesh Chandra; Saha, Archana

2014-01-01

Introduction: In Bipolar disorder the mood of the patients fluctuates between depression and mania. The main objective of the study was to find out the commonest mood stabilizers used for the treatment of Bipolar affective disorders in Western Nepal in hospitalized patients in an actual clinical set up. Methods: This was a cross-sectional study which was conducted between October 2009 and September 2010 at Psychiatric ward at Manipal teaching hospital, Pokhara, Nepal, a tertiary care hospital situated in Western Nepal. The diagnosis of the disease was based on ICD-10 (Tenth revision) Classification of mental and Behavioural disorders, Diagnostic Criteria for Research. We calculated odds ratio and their 95% confidence intervals (95% CI). p< 0.05 was considered as statistically significant. Results: 62.1% of the patients were less than 40 yrs, 56.3% were male, 72.4% were unemployed and 75.9% of the patients were having monthly income <10,000/month. As far as ethnicity is concerned 37.9% of the cases were Brahmin and by occupation 29.9% of the patients were students followed by housewife 25.3%, labour 17.2%, retired 13.8% respectively. Drugs and Psychotherapy [OR 1.4, 95% (CI 0.575, 3.4017)] was prescribed in age <40 years as compared to age>40 yrs. Male patients [OR 7.22, 95% (CI 0.862, 60.499)] and [OR 2.353, 95% (CI 0.857, 6.455)] received drugs by trade names and drugs not from the national drug list of Nepal as compared to females. Monthly income <10,000/month and [OR 2.8, 95% (CI 0.742, 10.56)] tendency of receiving drugs by trade names. Among the mood elevators Sodium valproate was the commonest drug to be prescribed in 51/87(58.6%) patients followed by Lithium in 30/87 (34.5%) cases and Carbamazepine in 6/87 (6.9%) cases. Sodium valproate was prescribed at 1,000 mg/day, Lithium was prescribed at 900 mg/day in and Carbamazepine was prescribed at 800 mg/day. Conclusion: Among all the mood elevators Sodium valproate is the commonest drug prescribed for the treatment of bipolar affective disorder, recommended that there is a trend of using newer drugs like sodium valproate rather than the conventional mood stabilizers like Lithium for bipolar affective disorder in Western Development region of Nepal. PMID:25121003

Treatment pathway and patterns of clozapine prescribing for schizophrenia in New Zealand.

PubMed

Wheeler, Amanda J

2008-06-01

To describe the treatment pathway and patterns of clozapine use in patients with schizophrenia, including coprescribed psychotropic medications, and compare the extent of coprescribing of clozapine with that of non-clozapine schizophrenia treatment in community mental health services in the Auckland and Northland regions of New Zealand. A retrospective chart review was conducted for adult outpatients receiving care from community mental health services on October 31, 2004. Data collected for all patients prescribed an antipsychotic included demographics (sex, age, ethnicity); principal diagnosis (Diagnostic and Statistical Manual of Mental Disorders, 4th edition); comorbid conditions; duration of mental illness; psychiatric admissions; and treatment information (psychotropic medications, with dose and route of administration). If clozapine had been started after the introduction of full government prescription subsidy (February 1999), additional data, including year of initiation and prior antipsychotic history, were collected. Analysis included all outpatients with a diagnosis of schizophrenia (including schizoaffective disorder). Antipsychotics were prescribed for 2796 schizophrenia patients; 32.8% were prescribed clozapine, with a mean dose of 372 mg/day and an average duration of illness of 9.7 years before starting clozapine. Patients who had started treatment after clozapine was funded by the government (59.3%) had received a median of 3 antipsychotic drugs prior to starting clozapine; most of the treatment regimens included 1 second-generation antipsychotic (91.2%). Clozapine patients were less likely to be coprescribed another antipsychotic compared with non-clozapine patients (11.7% vs 17.6%; p < 0.001). Both the clozapine and non-clozapine groups had a low total number of psychotropic medications prescribed (median 2); for clozapine patients, the second drug was most likely to be for treatment of hypersalivation. Outpatients with treatment-resistant schizophrenia were prescribed clozapine at expected rates; however, treatment was delayed longer than recommended. There is some evidence that access to clozapine for treatment-resistant schizophrenia has improved, possibly as the result of the introduction of government subsidy, guideline dissemination, or increasing experience of clinicians with use of clozapine. In this real-world environment, the number of concomitant psychotropic medications for outpatients with schizophrenia was found to be low; when used concomitantly with clozapine, they were most commonly used to manage adverse effects.

Combining statistical inference and decisions in ecology.

PubMed

Williams, Perry J; Hooten, Mevin B

2016-09-01

Statistical decision theory (SDT) is a sub-field of decision theory that formally incorporates statistical investigation into a decision-theoretic framework to account for uncertainties in a decision problem. SDT provides a unifying analysis of three types of information: statistical results from a data set, knowledge of the consequences of potential choices (i.e., loss), and prior beliefs about a system. SDT links the theoretical development of a large body of statistical methods, including point estimation, hypothesis testing, and confidence interval estimation. The theory and application of SDT have mainly been developed and published in the fields of mathematics, statistics, operations research, and other decision sciences, but have had limited exposure in ecology. Thus, we provide an introduction to SDT for ecologists and describe its utility for linking the conventionally separate tasks of statistical investigation and decision making in a single framework. We describe the basic framework of both Bayesian and frequentist SDT, its traditional use in statistics, and discuss its application to decision problems that occur in ecology. We demonstrate SDT with two types of decisions: Bayesian point estimation and an applied management problem of selecting a prescribed fire rotation for managing a grassland bird species. Central to SDT, and decision theory in general, are loss functions. Thus, we also provide basic guidance and references for constructing loss functions for an SDT problem. © 2016 by the Ecological Society of America.

Emergence of a new pair-coherent phase in many-body quenches of repulsive bosons

NASA Astrophysics Data System (ADS)

Fischer, Uwe R.; Lee, Kang-Soo; Xiong, Bo

2011-07-01

We investigate the dynamical mode population statistics and associated first- and second-order coherence of an interacting bosonic two-mode model when the pair-exchange coupling is quenched from negative to positive values. It is shown that for moderately rapid second-order transitions, a new pair-coherent phase emerges on the positive coupling side in an excited state, which is not fragmented as the ground-state single-particle density matrix would prescribe it to be.

Current Therapy of Acquired Ocular Toxoplasmosis: A Review.

PubMed

Lima, Guilherme Sturzeneker Cerqueira; Saraiva, Patricia Grativol Costa; Saraiva, Fábio Petersen

2015-11-01

Caused by the parasite Toxoplasma gondii, ocular toxoplasmosis (OT) is the most common form of posterior infectious uveitis. Combined antiparasitic therapy is the standard treatment for OT, but several other schemes have been proposed. The purpose of the present study was to review the literature on the treatment of OT and provide ophthalmologists with up-to-date information to help reduce OT-related visual morbidity. In conclusion, no ideal treatment scheme was identified; currently prescribed therapeutic schemes yield statistically similar functional outcomes.

Experiences of women in secure care who have been prescribed clozapine for borderline personality disorder.

PubMed

Dickens, Geoffrey L; Frogley, Catherine; Mason, Fiona; Anagnostakis, Katina; Picchioni, Marco M

2016-01-01

Clozapine is an atypical antipsychotic medicine which can cause significant side-effects. It is often prescribed off-license in severe cases of borderline personality disorder contrary to national treatment guidelines. Little is known about the experiences of those who take clozapine for borderline personality disorder. We explored the lived-experience of women in secure inpatient care who were prescribed clozapine for borderline personality disorder. Adult females ( N  = 20) participated in audio-taped semi-structured interviews. Transcripts were subject to thematic analysis. The central themes related to evaluation, wellbeing, understanding and self-management; for many, their subjective wellbeing on clozapine was preferred to prior levels of functioning and symptomatology, sometimes profoundly so. The negative and potentially adverse effects of clozapine were explained as regrettable but relatively unimportant. When psychological interventions are, at least initially, ineffective then clozapine treatment is likely to be evaluated positively by a group of women with borderline personality disorder in secure care despite the potential disadvantages.

The role of veterinarians and feed-store vendors in the prescription and use of antibiotics on small dairy farms in rural Peru

PubMed Central

Redding, L. E.; Barg, F. K.; Smith, G.; Galligan, D. T.; Levy, M. Z.; Hennessy, S.

2014-01-01

This study aimed to describe and compare the role of veterinarians and feed-store vendors in the use of antibiotics on small dairy farms in Cajamarca, Peru, a major dairy-producing center characterized by small, rural farms with poor, mostly uneducated farmers. We used a purposive sampling strategy to recruit 12 veterinarians into 2 focus group discussions and supplemented these data with 8 semi-structured interviews with feed-store vendors. Participants reported that inappropriate antibiotic usage was widespread among their clients, which may prevent the efficient use of drugs on farms where animal disease can be devastating to the livelihood of the farmer. Participants also identified many barriers to appropriate prescribing and use, including availability of drugs, competition from other prescribers, economic constraints and habits of farmers, and limited farmer knowledge of drugs and disease. Veterinarians expressed mistrust toward nonprofessional prescribers, whereas feed-store vendors felt that veterinarians were important partners in promoting the health of their clients’ animals. PMID:24054290

Barriers to and Facilitators of Antiretroviral Therapy Adherence in Nepal: A Qualitative Study

PubMed Central

Simkhada, Padam; Randall, Julian; Freeman, Jennifer V; van Teijlingen, Edwin

2012-01-01

Patient's adherence is crucial to get the best out of antiretroviral therapy (ART). This study explores in-depth the barriers to and facilitators of ART adherence among Nepalese patients and service providers prescribing ART. Face-to-face semi-structured interviews were conducted with 34 participants. Interviews were audio-taped, transcribed, and translated into English before being analyzed thematically. ART-prescribed patients described a range of barriers for failing to adhere to ART. Financial difficulties, access to healthcare services, frequent transport blockades, religious/ritual obstacles, stigma and discrimination, and side-effects were the most-frequently discussed barriers whereas trustworthy health workers, perceived health benefits, and family support were the most-reported facilitators. Understanding barriers and facilitators can help in the design of an appropriate and targeted intervention. Healthcare providers should address some of the practical and cultural issues around ART whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients. PMID:23304907

The effect of coherent stirring on the advection–condensation of water vapour

PubMed Central

Vanneste, Jacques

2017-01-01

Atmospheric water vapour is an essential ingredient of weather and climate. The key features of its distribution can be represented by kinematic models which treat it as a passive scalar advected by a prescribed flow and reacting through condensation. Condensation acts as a sink that maintains specific humidity below a prescribed, space-dependent saturation value. To investigate how the interplay between large-scale advection, small-scale turbulence and condensation controls moisture distribution, we develop simple kinematic models which combine a single circulating flow with a Brownian-motion representation of turbulence. We first study the drying mechanism of a water-vapour anomaly released inside a vortex at an initial time. Next, we consider a cellular flow with a moisture source at a boundary. The statistically steady state attained shows features reminiscent of the Hadley cell such as boundary layers, a region of intense precipitation and a relative humidity minimum. Explicit results provide a detailed characterization of these features in the limit of strong flow. PMID:28690417

The effect of coherent stirring on the advection-condensation of water vapour

NASA Astrophysics Data System (ADS)

Tsang, Yue-Kin; Vanneste, Jacques

2017-06-01

Atmospheric water vapour is an essential ingredient of weather and climate. The key features of its distribution can be represented by kinematic models which treat it as a passive scalar advected by a prescribed flow and reacting through condensation. Condensation acts as a sink that maintains specific humidity below a prescribed, space-dependent saturation value. To investigate how the interplay between large-scale advection, small-scale turbulence and condensation controls moisture distribution, we develop simple kinematic models which combine a single circulating flow with a Brownian-motion representation of turbulence. We first study the drying mechanism of a water-vapour anomaly released inside a vortex at an initial time. Next, we consider a cellular flow with a moisture source at a boundary. The statistically steady state attained shows features reminiscent of the Hadley cell such as boundary layers, a region of intense precipitation and a relative humidity minimum. Explicit results provide a detailed characterization of these features in the limit of strong flow.

The effect of coherent stirring on the advection-condensation of water vapour.

PubMed

Tsang, Yue-Kin; Vanneste, Jacques

2017-06-01

Atmospheric water vapour is an essential ingredient of weather and climate. The key features of its distribution can be represented by kinematic models which treat it as a passive scalar advected by a prescribed flow and reacting through condensation. Condensation acts as a sink that maintains specific humidity below a prescribed, space-dependent saturation value. To investigate how the interplay between large-scale advection, small-scale turbulence and condensation controls moisture distribution, we develop simple kinematic models which combine a single circulating flow with a Brownian-motion representation of turbulence. We first study the drying mechanism of a water-vapour anomaly released inside a vortex at an initial time. Next, we consider a cellular flow with a moisture source at a boundary. The statistically steady state attained shows features reminiscent of the Hadley cell such as boundary layers, a region of intense precipitation and a relative humidity minimum. Explicit results provide a detailed characterization of these features in the limit of strong flow.

Knowledge, attitude and perception of medical and dental undergraduates about antimicrobial stewardship

PubMed Central

Sharma, Kopal; Jain, Pushpawati; Sharma, Amit

2015-01-01

Objectives: This study aimed to identify the current knowledge, attitude, and perception (KAP) of the future prescribers about antimicrobial (AM) education so that the identified lacunae in the training curriculum can be effectively addressed. Materials and Methods: A questionnaire-based survey was carried out in the 2nd year students of medical and the dental undergraduate (UG) courses at a tertiary care teaching center in Jaipur. Each respondent completed the given questionnaire independently in the allocated time. A scoring system was used to rate the KAP of the respondents as poor, average, or good. Results: Statistically significant differences were found in the KAP of the medical and dental future prescribers (P = 0.0086, 0.0002, and <0.0001 for the KAP, respectively). Conclusion: The attitude of the UG students towards AM education is good, but the deficiencies in the knowledge and perception need to be improved further. Suitable interventions to address these lacunae must be planned. PMID:26729963

Prescribing by general practitioners after an osteoporotic fracture.

PubMed

Torgerson, D J; Dolan, P

1998-06-01

Osteoporosis is a major cause of morbidity and cost. Patients sustaining one osteoporotic fracture are at increased risk of having another fracture. The objective of this study was to examine the use of "bone drugs" for the prevention of further osteoporotic fractures among patients who have had a "typical" osteoporotic fracture. This study took a random sample of 300 women aged 50 and over who had sustained either a vertebral, hip or Colles fracture in 1995 from the General Practice Research Database (GPRD) and compared their use of bone drugs with 300 age and practice matched controls. Compared with age and practice matched control patients only vertebral fracture patients showed a statistically significant increase in the use of bone drugs in the year after fracture (39% and 2% for cases and controls respectively; 95% CI of difference 27% to 47%). Etidronate was the most commonly used compound. The majority of patients sustaining an osteoporotic fracture are not prescribed any pharmaceutical agents for the secondary prevention of fracture one year after a primary fracture.

Microwave detection of fatigue cracks in specially prepared steel specimens.

DOT National Transportation Integrated Search

1998-01-01

In the aging highway systems the problems of fatigue-induced damage and cracking in metal structures are very severe. Many such systems are operating even beyond their design lifetime, which requires more than the originally prescribed inspection cyc...

Long-term effects of fire and fire-return interval on population structure and growth of longleaf pine (Pinus palustris)

Treesearch

Chelcy R. Ford; Emily S. Minor; Gordon A. Fox

2010-01-01

We investigated the effect of fire and fire frequency on stand structure and longleaf pine (Pinus palustris P. Mill.) growth and population demography in an experimental research area in a southwest Florida sandhill community. Data were collected from replicated plots that had prescribed fire-return intervals of 1, 2, 5, or 7 years or were left...

Optimizing psychosocial support during office-based buprenorphine treatment in primary care: patients’ experiences and preferences

PubMed Central

Fox, Aaron D.; Masyukova, Mariya; Cunningham, Chinazo O.

2015-01-01

Background Buprenorphine maintenance treatment is effective and has been successfully integrated into HIV and primary care settings. However, one key barrier to providers prescribing buprenorphine is their perception that they are unable to provide adequate counseling or psychosocial support to patients with opioid addiction. This qualitative study investigated supportive elements of office-based buprenorphine treatment that patients perceived to be most valuable. Methods We conducted five focus groups with 33 buprenorphine treatment-experienced participants. Focus groups were audio-recorded and transcribed. Iterative readings of transcripts and grounded theory analysis revealed common themes. Results Overall, participants perceived that buprenorphine treatment helped them to achieve their treatment goals and valued the flexibility, accessibility, and privacy of treatment. Participants identified interpersonal and structural elements of buprenorphine treatment that provided psychosocial support. Participants desired good physician-patient relationships, but also valued care delivery models that were patient-centered, created a safe place for self-disclosure, and utilized coordinated team-based care. Conclusions Participants derived psychosocial support from their prescribing physician, but were also open to collaborative or team-based models of care, as long as they were voluntary and confidential. Buprenorphine prescribing physicians without access to referral options for psychosocial counseling could focus on maintaining non-judgmental attitudes and shared decision making during patient encounters. Adding structure and psychosocial support to buprenorphine treatment through coordinated team-based care also seems to have great promise. PMID:26566712