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Our objective was to make recommendations intended to reduce the rate of opioid misuse and overdose for a particularly high-risk group of people with traumatic brain injury (TBI). A consensus process conducted with TBI researchers and expert practitioners developed practical recommendations to inform prescribing of opioids for people with TBI. After determining key general principles for prescribing opioids for people with TBI, 6 TBI-specific recommendations were developed, 1 for acute pain in the agitated patient with TBI, 3 recommendations to be considered before prescribing an opioid, and 2 for follow-up and use by mental health and substance use disorder providers. While there is much needed research to examine the relationship between opioid misuse and TBI, the present recommendations provide at least some clinical considerations that might serve to prevent further deaths among a high-risk group., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the effect of implementing standardized opioid prescribing guidelines on prescription patterns for acute pain after ophthalmic surgery in opioid-naïve patients., Design: Quality improvement study., Participants: Ophthalmic surgeons in an academic department of ophthalmology., Methods: Postoperative opioid prescribing patterns were compared before and after the implementation of standardized opioid prescribing guidelines for ophthalmic surgery at an academic institution. Only prescriptions provided to opioid-naïve patients 18 years of age or older were included. Surgeons reached a consensus for standardized prescribing guidelines appropriate for the type of surgery within their subspecialty. Guidelines were disseminated in conjunction with postsurgical pain management education to all ophthalmologists in the department, including trainees. The frequency of opioid prescriptions, the quantity of opioid prescribed (converted to oral morphine equivalent [OME]), and opioid prescription refill rates were compared before and after intervention., Main Outcome Measures: Prescriptions with more than 80 OME, frequency of opioid prescriptions, mean OME, and refill rates., Results: Of 5349 ophthalmic surgeries performed during the 2 assessment periods, 196 (3.7%) were associated with opioid prescriptions for acute postoperative pain. The frequency of opioid prescriptions decreased to 3.0% (81/2736) after intervention compared with 4.4% (115/2613) before intervention (P = 0.005). When opioids were prescribed, the mean OME decreased from 93 (range, 27-500) before intervention to 42 (range, 14-100) after intervention (P = 0.003). The number of prescriptions for more than 80 OME decreased from 56 (2.1%) before intervention to 4 (0.1%) after intervention (P < 0.001). Based on the standardized guidelines, 103 of the 115 (89.6%) preintervention opioid prescriptions would not have adhered to the guidelines, whereas 39 of the 81 (48.1%) postintervention prescriptions did not adhere to the guidelines (P < 0.001). The proportion of refill prescriptions did not differ before and after intervention (P = 0.44)., Conclusions: The process of discussing postsurgical pain management and developing standardized opioid prescribing guidelines reduces overprescribing of opioids after ophthalmic surgery without increasing refill rates. Continued education is required to improve adherence to the prescribing guidelines further., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Importance: Concerns about adverse outcomes associated with opioid analgesic prescription have led to major guideline and policy changes. Substantial uncertainty remains, however, regarding the association between opioid prescription initiation and increased risk of subsequent substance-related morbidity., Objective: To examine the association of opioid initiation among adolescents and young adults with subsequent broadly defined substance-related morbidity., Design, Setting, and Participants: This cohort study analyzed population-register data from January 1, 2007, to December 31, 2013, on Swedish individuals aged 13 to 29 years by January 1, 2013, who were naive to opioid prescription. To account for confounding, the analysis compared opioid prescription recipients with recipients of nonsteroidal anti-inflammatory drugs as an active comparator, compared opioid-recipient twins and other multiple birth individuals with their nonrecipient co-multiple birth offspring (co-twin control), examined dental prescription as a specific indication, and included individual, parental, and socioeconomic covariates. Data were analyzed from March 30, 2019, to January 22, 2020., Exposures: Opioid prescription initiation, defined as first dispensed opioid analgesic prescription., Main Outcomes and Measures: Substance-related morbidity, assessed as clinically diagnosed substance use disorder or overdose identified from inpatient or outpatient specialist records, substance use disorder or overdose cause of death, dispensed pharmacotherapy for alcohol use disorder, or conviction for substance-related crime., Results: Among the included cohort (n = 1 541 862; 793 933 male [51.5%]), 193 922 individuals initiated opioid therapy by December 31, 2013 (median age at initiation, 20.9 years [interquartile range, 18.2-23.6 years]). The active comparator design included 77 143 opioid recipients without preexisting substance-related morbidity and 229 461 nonsteroidal anti-inflammatory drug recipients. The adjusted cumulative incidence of substance-related morbidity within 5 years was 6.2% (95% CI, 5.9%-6.5%) for opioid recipients and 4.9% (95% CI, 4.8%-5.1%) for nonsteroidal anti-inflammatory drug recipients (hazard ratio, 1.29; 95% CI, 1.23-1.35). The co-twin control design produced comparable results (3013 opioid recipients and 3107 nonrecipients; adjusted hazard ratio, 1.43; 95% CI, 1.02-2.01), as did restriction to analgesics prescribed for dental indications and additional sensitivity analyses., Conclusions and Relevance: Among adolescents and young adults analyzed in this study, initial opioid prescription receipt was associated with an approximately 30% to 40% relative increase in risk of subsequent substance-related morbidity in multiple designs that adjusted for confounding. These findings suggest that this increase may be smaller than previously estimated in some other studies.

Background: A vigilant prescription of drugs during pregnancy can potentially safeguard the growing fetus from the deleterious effect of the drug while attempting to manage the mother's health problems. There is a paucity of information about the drug utilization pattern in the area of investigation. Hence, this study was implemented to investigate the pattern of drug utilization and its associated factors among pregnant women in Adigrat general hospital, Northern Ethiopia., Methods: An institution-based cross-sectional study was conducted among randomly selected 314 pregnant women who attended obstetrics-gynecology and antenatal care units of the hospital. Relevant data were retrieved from the pregnant women's medical records and registration logbook. The drugs prescribed were categorized based on the United States Food and Drug Administration (US-FDA) fetal harm classification system. Data analysis was done using SPSS version 20 statistical software. Multivariate logistic regression was employed to analyze the association of the explanatory variables with the medication use, and p < 0.05 was declared statistically significant., Results: The overall prescribed drug use in this study was found to be 87.7%. A considerable percentage of the study participants (41.4%) were prescribed with supplemental drugs (iron folate being the most prescribed drug) followed by antibiotics (23.4%) and analgesics (9.2%). According to the US-FDA drug's risk classification, 42.5, 37, 13, and 7% of the drugs prescribed were from categories A, B, C, and D or X respectively. Prescribed drug use was more likely among pregnant women who completed primary [AOR = 5.34, 95% CI (1.53-18.6)] and secondary education [AOR = 4.1, 95% CI (1.16-14)], who had a history of chronic illness [AOR = 7.9, 95% CI (3.14-19.94)] and among multigravida women [AOR = 2.9, 95% CI (1.57 5.45)]., Conclusions: The finding of this study revealed that a substantial proportion of pregnant women received drugs with potential harm to the mother and fetus. Reasonably, notifying health practitioners to rely on up-to-date treatment guidelines strictly is highly demanded. Moreover, counseling and educating pregnant women on the safe and appropriate use of medications during pregnancy are crucial to mitigate the burden that the mother and the growing fetus could face.

Purpose: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have demonstrated glycemic efficacy and cardiovascular and renal benefits in people with type 2 diabetes mellitus (T2DM). However, they are also associated with serious adverse events (AEs), but little consensus exists for clinicians regarding AE management. This study aimed to develop a list of best practices for the safe use and monitoring of SGLT-2 inhibitors in people with T2DM., Methods: A 15-member interprofessional panel was surveyed in a four-round Delphi process. Panelists were asked to comment on and rank statements regarding initial prescribing considerations and actions for minimizing and managing eight specific AEs and a broad category for other AEs. In the final round, panelists selected if the statements should be considered a best practice specific to SGLT-2 inhibitors, a best practice for general safe medication use in T2DM, or if the statement should not be considered as a best practice for safe medication use., Results: Consensus was achieved for 36 best practice statements specific to SGLT-2 inhibitors and 24 statements as general best practices for safe medication use. Fifty-six percent of the best practice statements for SGLT-2 inhibitors related to managing and/or preventing hypotension, urinary tract infections, and genital infections. The general best practices for safe medication use primarily focused on medication histories, past medical history considerations, physical exam components, and patient education., Conclusion: A list of best practice statements was developed using the Delphi method, which can be utilized by clinicians to guide the safe use and monitoring of SGLT-2 inhibitors in people with T2DM., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The perioperative analgesic plan begins with preoperative planning. The surgeon should be versed in practical approaches for managing analgesia in patients with chronic pain. The first step includes evaluating the patient and conducting a focused pain history. Confirming, documenting, and understanding current outpatient prescriptions is critical. Patients should be screened for medical conditions that preclude the use of certain analgesics, or place them at higher risk of respiratory depression. Providers should coordinate with the patient's outpatient prescribers and pain specialists to ensure a safe and effective analgesic plan. Multimodal analgesia should be implemented to optimize analgesia and decrease opioid requirements., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Nearly 50,000 US adults experience opioid-overdose deaths annually and 1.7 million experience a substance use disorder from prescription opioids. Hence, understanding analgesia strategies is of utmost importance. A pre-operative analgesic plan can consist of a brief conversation between the surgeon, patient, and anesthesiologist in an uncomplicated case or range all the way to an involved, multidisciplinary plan for a chronic pain patient. Over the past several decades, there have been myriad studies examining perioperative analgesic regimens for otolaryngologic procedures, many of which have demonstrated the efficacy of nonopioid analgesics., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The overutilization of healthcare and overuse/misuse of antibiotics in Japan are responsible for the increase in healthcare expenditure and the development of antimicrobial resistance. The Japanese government started paying incentives to medical facilities for primary care physician registrations, but the impact of this new policy is still unclear., Methods: We conducted a retrospective cohort study for all pediatric outpatients from April 2015 to December 2016 in Japan, targeting 1.4 million children under 2 years of age. We investigated the effects of primary care physician registration on physician visits, total antibiotic use and admission rates using difference-in-differences (DID) and causal mediation analyses., Results: DID analyses showed that primary care registration policy contributed to increases in total physician visits, total and broad-spectrum antibiotic use and radiologic study utilization, but reduced out-of-hour visits and did not affect hospitalization rates. Similar results were obtained when we adjusted for and matched on potential confounders. Causal mediation analyses found that the greatest pathway was controlled by direct effects of 53.2 DOTs per 1000 person-months (95% CI: 29.1-77.2), indicating that the effect of new health policy that did not mediate increased outpatient visits mostly contributed to the excess use of antibiotics., Conclusions: The health policy further increased antibiotic use. On April 2018, a new health policy of paying incentives for not prescribing antibiotics to children with respiratory infection or gastroenteritis was initiated. Further studies are needed whether this new health policy can mitigate the overutilization of healthcare and antibiotic use.

Objective: This comprehensive review examined sex differences in prescription rates and efficacy or effectiveness of pharmacotherapy treatment in girls and women with attention deficit hyperactivity disorder (ADHD), while identifying gaps in the scientific knowledge on this topic., Method: A rigorous electronic database search was carried out in order to identify all published studies on female-specific effects of stimulants and non-stimulants in the treatment of ADHD. In total, 2672 studies were screened of which 21 studies (seven on prescription rates, 14 on effects of pharmacotherapy) met the inclusion criteria and were included for analysis., Results: In all seven studies on ADHD prescription rates, girls received significantly less prescriptions than boys, a difference however no longer seen in adults with the exception of one study. Each of the 14 studies on effectiveness / efficacy found at least one sex-difference in the effects of ADHD pharmacotherapy., Conclusion: Several sex-differences are demonstrated in the prescription, usage and efficacy /effectiveness of both stimulant and non-stimulant ADHD pharmacotherapy. A single daily use of MPH may possibly not be optimal for girls with ADHD and ATX may be a promising medication for girls and women with ADHD. The robustness of this result requires further investigation., Competing Interests: The authors have declared that no competing interests exist.

Background: Clinical studies found that the combination of traditional Chinese herbal formula, and western medicine therapy are better in shrinking fibroids and improve other symptoms. This study aims to systematically evaluate the efficacy and safety traditional Chinese herbal formula combined with western medicine in the treatment of uterine fibroids., Methods: Randomized controlled trials of traditional Chinese herbal formula combined with western medicine for uterine fibroids patients will be searched in PubMed, Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chongqing VIP Chinese Science and Technology Periodical Database, Chinese Biological and Medical database (CMB), and Wanfang database from inception to August 2020. Two researchers will perform data extraction and risk of bias assessment independently. Statistical analysis will be conducted in RevMan 5.3., Results: This study will summarize the present evidence by exploring the efficacy and safety of traditional Chinese herbal formula combined with western medicine in the treatment of uterine fibroids CONCLUSIONS:: The findings of the study will help to determine potential benefits of traditional Chinese herbal formula combined with western medicine in the treatment of uterine fibroids., Ethics and Dissemination: The private information from individuals will not be published. This systematic review also will not involve endangering participant rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences., Osf Registration Number: DOI 10.17605/OSF.IO/XUA8V.

Background: Traditional Chinese medicine (TCM) or combined with western medicine in the treatment of pediatric adenoidal hypertrophy has been widely used in clinical practice, but the overall efficacy and safety is still unclear. This paper aims to evaluate the efficacy and safety analysis of TCM or combined with western medicine for pediatric adenoidal hypertrophy., Methods: PubMed, EMbase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, the Chongqing VIP Chinese Science and Technology Periodical Database, and China biomedical literature database (CBM) were searched for randomized controlled trials of TCM or combined with western medicine for pediatric adenoidal hypertrophy from the date of establishment to July 2020, and Baidu Scholar, Google Scholar, International Clinical Trials Registry Platform (ICTRP), and Chinese Clinical Trials Registry (ChiCTR) were searched for unpublished grey literature. Two researchers independently applied RevMan 5.3 software for data extraction and risk assessment of bias., Results: The effectiveness and safety of TCM or combined with western medicine for pediatric adenoidal hypertrophy is evaluated by means of the Adenoid (A) /(Nasopharyngeal (N) ratio, clinical efficacy, integral score of TCM syndromes, clinical single symptom score, disease specific quality of life for children with obstructive sleep apnea 18 items survey (OSA-18), Interleukin 4 (IL-4) and adverse reaction incidence., Conclusion: This study will provide theoretical support for the clinical application of TCM or combined with western medicine for pediatric adenoidal hypertrophy., Osf Registration Number: DOI 10.17605/OSF.IO/J76AG.

Background: According to previous studies, older patients frequently have serum concentrations of antidepressant medication above the recommended reference range., Objective: The aim of this study was to investigate whether prescribed doses of antidepressants and the proportion of individuals with serum concentrations above the recommended reference range in older individuals (≥ 65 years) have changed over a 10-year period in Norway., Methods: Serum concentration measurements and prescribed daily doses of antidepressants in 2007 and 2017 were extracted from a therapeutic drug monitoring (TDM) database at the Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway. The database contains routine follow-up serum concentration measurements of psychotropic drugs for patients from all parts of the country. For citalopram, escitalopram, sertraline, mirtazapine and venlafaxine, the differences between 2007 and 2017 in mean prescribed doses and the proportion of patients with at least one serum concentration above the reference range, according to the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) guidelines, were compared. For the proportion of patients with serum concentrations above the recommended reference range, differences between individuals aged 65-79 and ≥ 80 years were also examined., Results: The analyses of prescribed doses included 806 patients from 2007 and 1932 patients from 2017, with 972 and 2441 TDM samples, respectively. Between 2007 and 2017, modest reductions in prescribed daily doses were observed for citalopram (20 vs. 17 mg/day) and escitalopram (11 vs. 10 mg/day), but the proportion of patients with serum concentrations above the recommended reference range was unchanged for both drugs, i.e. 11.5% vs. 12.4% for citalopram and 3.6% vs. 2.9% for escitalopram. For mirtazapine and venlafaxine, prescribed doses were reduced from 28 to 25 mg/day and 150 to 125 mg/day, respectively. A significant reduction in the proportion of individuals with serum concentrations above the recommended reference range was observed for mirtazapine (27.1% vs. 11.5%) and for individuals aged ≥ 80 years using venlafaxine (60.0% vs. 30.0%). For sertraline, no differences in prescribed doses or serum concentrations above the recommended reference range were observed., Conclusions: Over a 10-year period, prescribed doses of antidepressants have been slightly reduced in older Norwegian patients, but a considerable proportion is still exposed to high serum concentrations of antidepressants.

Background: In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems., Aims: Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes., Outcomes: Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions., Conclusions: There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Background: Medical curricula need to provide adequate knowledge on antimicrobial medicine use and antimicrobial resistance (AMR). Such knowledge is critical in shaping correct attitudes and perceptions among future prescribers. However, the extent of preparation provided by medical curricula remains unknown., Aim: The current study sought to determine knowledge, attitude and perception on antimicrobial use and AMR among final year medical students in Malawi., Methods: A descriptive cross-sectional study was undertaken among all final year medical students at the College of Medicine, University of Malawi in 2016. Total population sampling and self-administered questionnaires were used. Data were entered using Microsoft Excel and analysed with Epi info. Descriptive analysis for categorical data was done using frequencies and proportions, and for continuous data using measures of central tendency., Results: The response rate in this study was 95%. The mean and median aggregated scores were 7.2 and 7, respectively, for the 11 knowledge questions. Over 88% of the respondents answered more than half of the knowledge questions correctly. Respondents agreed that antimicrobials are overused both at national (50; 69%) and at hospital (52; 72%) levels., Conclusion: This study reports high aggregated knowledge scores on antimicrobial use and resistance with wide variations on correct knowledge scores per question. The study further shows varying level in attitudes and perceptions among medical students. Overall, there were gaps on antimicrobial use and knowledge of AMR which the medical curriculum should addresses., (© 2020 The College of Medicine and the Medical Association of Malawi.)

Background: The SENATOR trial intervention included the provision of computer-generated medication recommendations to physician prescribers caring for hospitalised older adults (≥ 65 years), with the aim of reducing in-hospital adverse drug reactions. Interim data analysis during the trial revealed that the prescriber implementation rates of the computer-generated STOPP/START recommendations were lower than expected across all six trial sites., Aim: The aim of this qualitative study was to identify the factors affecting prescriber implementation of the medication recommendations in the SENATOR trial., Methods: Semi-structured interviews were conducted with trial researchers and physician prescribers who were provided with SENATOR recommendations. Content analysis was used to identify the most relevant domains from the Theoretical Domains Framework (TDF) that affected recommendation uptake., Results: Ten trial researchers and fourteen prescribers were interviewed across the six trial sites. Eight TDF domains were found to be most relevant in affecting prescriber implementation: 'environmental context and resources', 'goals', 'intentions', 'knowledge', 'beliefs about consequences', 'memory, attention and decision processes', 'social/professional role and identity', and 'social influences'. Interviewees felt that there was often a disconnect between the time prescribers were reviewing the patient and the point at which the recommendations were provided. However, when recommendations were reviewed, prescriber inertia was highly pervasive, with a particular reluctance to make pharmacotherapy changes outside their own specialty. Implementation was facilitated by recommendations reaching a 'decision-maker', but this was often not possible as the software could not evaluate the entire clinical context of patients, and thus frequently produced recommendations of low clinical relevance., Conclusion: This study has demonstrated that the clinical relevance of the SENATOR prescribing recommendations was a significant factor affecting their implementation. Whilst software refinement will be necessary to improve the quality of recommendations, future interventions will need to be multifaceted to overcome the complex prescriber specialty culture within the acute hospital environment.

Introduction and Objectives: Despite the recommendation against routine use of inhaled bronchodilators in infants with viral bronchiolitis given in the main clinical practice guidelines (CPGs) on viral bronchiolitis, albuterol is widely prescribed to patients with this disease. The aim of this study was to identify predictors of prescription of albuterol in a population of infants hospitalized for viral bronchiolitis., Material and Methods: An analytical cross-sectional study performed during the period from March 2014 to August 2015, in a random sample of patients <2 years old hospitalized in the Fundacion Hospital La Misericordia, a hospital located in Bogota, Colombia. After reviewing the electronic medical records, we collected demographic, clinical, and disease-related information, including prescription of albuterol at any time during the course of hospitalization as the outcome variable., Results: For a total of 1365 study participants, 1042 (76.3%) were prescribed with albuterol therapy. After controlling for potential confounders, it was found that age (OR 1.11; CI 95% 1.08-1.15; p<0.001), and a prolonged length of stay (LOS) (OR 1.93; CI 95% 1.44-2.60; p<0.001) were independent predictors of prescription of albuterol in our sample of patients. By contrast, albuterol prescription was less likely in the post-guideline assessment period (OR 0.41; CI 95% 0.31-0.54; p<0.001), and in infants with RSV isolation (OR 0.71; CI 95% 0.52-0.97; p=0.035)., Conclusions: Albuterol was highly prescribed in our population of inpatients with the disease. The independent predictors of prescription of albuterol in our sample of patients were age, implementation of a CPG on viral bronchiolitis, RSV isolation, and LOS., (Copyright © 2020 SEICAP. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To describe the usage patterns of antidepressants with published CYP2D6- and CYP2C19-based prescribing guidelines among depressed primary care patients and estimate the proportion of patients taking antidepressants not recommended for them based on their CYP2C19 and CYP2D6 genotype-predicted metabolizer status., Methods: Medication use and pharmacogenetic testing results were collected on 128 primary care patients enrolled in a 10-year depression cohort study. At each 12-month interval, we calculated the proportion of patients that: (1) reported use of one or more of the 13 antidepressant medications (i.e. amitriptyline, citalopram, escitalopram, clomipramine, desipramine, doxepin, fluvoxamine, imipramine, nortriptyline, paroxetine, sertraline, trimipramine, venlafaxine) with published CYP2D6- and CYP2C19-based prescribing guidelines, (2) were taking an antidepressant that was not recommended for them based on their CYP2C19 and CYP2D6 genotype-predicted metabolizer phenotype, and (3) switched medications from the previous 12-month interval., Results: The annual proportion of individuals taking an antidepressant with a CYP2D6- and CYP2C19-based prescribing guidelines ranged from 45 to 84%. The proportion of participants that used an antidepressant that was not recommended for them, based on available CYP2D6 and CYP2C19 metabolizer phenotype, ranged from 18 to 29% and these individuals tended to switch medications more frequently (10%) compared to their counterparts taking medication aligned with their metabolizer phenotype (6%)., Conclusion: One-quarter of primary care patients used an antidepressant that was not recommended for them based on CYP2D6- and CYP2C19-based prescribing guidelines and switching medications tended to be more common in this group. Studies to determine the impact of CYP2D6 and CYP2C19 genotyping on reducing gene-antidepressant mismatches are warranted.

Background: The rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community with full information and with the lowest possible cost. If one of these is not met, it is referred to as irrational drug use. Many drugs have been sold or prescribed inappropriately in the world, and a significant part of the world population lacks access to essential medicine. The aim of this study was to assess practice towards rational drug use at Finoteselam and Asirade Zewudie hospitals., Methods: A cross-sectional study design was used for this study, and the study was conducted from October 11 to November 30, 2019. A total of 770 prescriptions were selected as per WHO criteria by using systematic random sampling and reviewed with the help of an observational checklist. The data were entered and processed with SPSS version 25 and evaluated using the WHO criteria., Result: The average number of drugs per prescription was 1.8 and 2.05, antibiotics encountered were 77.7% and 72.5%, injections encountered were 5.97% and 7.01%, percentage of drugs prescribed by generic names was 97% and 93.4%, counseling time was 1.6 minutes and 2.25 minutes, and dispensing time was 51.3 seconds and 62.72 seconds at Finoteselam and Asirade Zewudie hospitals, respectively., Conclusion: The majority of WHO core drug use indicators were not met in the two hospitals. The average number of drugs encountered in Asirade Zewudie hospital was slightly higher than the WHO recommended range, whereas the average number of drugs encountered in Finoteselam hospital was exactly equal. The percentage of antibiotics encountered was very high compared with WHO recommendation, but the percentage of injections encountered was below the WHO recommended range and time spent on counseling and dispensing was too short when compared with WHO recommendation. In addition to this, both hospitals had no essential drug list or formulary as well as a key drug list., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2020 Bekalu Dessie et al.)

Background: Inappropriate prescribing in the elderly is a critical issue in primary care, causing a higher risk of Adverse Drug Reactions (ADRs) and resulting in major patient safety concerns. At international level, many tools have been developed to identify Potentially Inappropriate Medications (PIMs)., Objective: The aim of this study was the application of Beers, Screening Tool of Older People's Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) and Improving Prescribing in the Elderly Tool (IPET) criteria as key tool to improve the quality of prescribing., Methods: A retrospective study was conducted using the aforementioned criteria. Two different cohorts of elderly patients were enrolled between January 2015 and December 2016, 1800 at admission and 1466 at hospital stay. The index of each criterion divided by politherapy were correlated with comorbidities (Pearson correlation). A comparison was made between admission and hospital stay through a Student's t test of the average of the index., Results: The Proton Pump Inhibitors (PPIs) were the most prescribed PIMs according Beers criteria in both patient cohorts (56%). The most detected drug-drug and drug-disease interactions at admission and at hospital stay were 3 or more drugs active on the Central Nervous System (CNS) as they can predispose to fall-risk. The most detected PIMs with STOPP criteria at admission were PPIs administered for more than 8 weeks. Inhaled β2-agonists or antimuscarinics were the most prescribed Potential Prescription Omissions (PPOs) according to START criteria. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in patients with high blood pressure were the most detected PIMs according to IPET criteria during hospital stay. A significant correlation between the comorbidities and the all index at hospital stay, while at admission there was no significant correlation for Beers and IPET index., Conclusion: The prescriptive criteria were a useful tool for assessing the quality of prescriptions in the geriatric population and identifying their critical issues., Competing Interests: We have no conflicts of interest to disclose.

Background: Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices., Methods: Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction., Results: There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction., Conclusions: Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial., Competing Interests: Manish M. Sood has received grant funding from Otsuka and speaker fees from Astrazeneca unrelated to this study. All other authors have no conflicts to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: The prescription rate of antibiotics is high for febrile children visiting the emergency department (ED), contributing to antimicrobial resistance. Large studies at European EDs covering diversity in antibiotic and broad-spectrum prescriptions in all febrile children are lacking. A better understanding of variability in antibiotic prescriptions in EDs and its relation with viral or bacterial disease is essential for the development and implementation of interventions to optimise antibiotic use. As part of the PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union) project, the MOFICHE (Management and Outcome of Fever in Children in Europe) study aims to investigate variation and appropriateness of antibiotic prescription in febrile children visiting EDs in Europe., Methods and Findings: Between January 2017 and April 2018, data were prospectively collected on febrile children aged 0-18 years presenting to 12 EDs in 8 European countries (Austria, Germany, Greece, Latvia, the Netherlands [n = 3], Spain, Slovenia, United Kingdom [n = 3]). These EDs were based in university hospitals (n = 9) or large teaching hospitals (n = 3). Main outcomes were (1) antibiotic prescription rate; (2) the proportion of antibiotics that were broad-spectrum antibiotics; (3) the proportion of antibiotics of appropriate indication (presumed bacterial), inappropriate indication (presumed viral), or inconclusive indication (unknown bacterial/viral or other); (4) the proportion of oral antibiotics of inappropriate duration; and (5) the proportion of antibiotics that were guideline-concordant in uncomplicated urinary and upper and lower respiratory tract infections (RTIs). We determined variation of antibiotic prescription and broad-spectrum prescription by calculating standardised prescription rates using multilevel logistic regression and adjusted for general characteristics (e.g., age, sex, comorbidity, referral), disease severity (e.g., triage level, fever duration, presence of alarming signs), use and result of diagnostics, and focus and cause of infection. In this analysis of 35,650 children (median age 2.8 years, 55% male), overall antibiotic prescription rate was 31.9% (range across EDs: 22.4%-41.6%), and among those prescriptions, the broad-spectrum antibiotic prescription rate was 52.1% (range across EDs: 33.0%-90.3%). After standardisation, differences in antibiotic prescriptions ranged from 0.8 to 1.4, and the ratio between broad-spectrum and narrow-spectrum prescriptions ranged from 0.7 to 1.8 across EDs. Standardised antibiotic prescription rates varied for presumed bacterial infections (0.9 to 1.1), presumed viral infections (0.1 to 3.3), and infections of unknown cause (0.1 to 1.8). In all febrile children, antibiotic prescriptions were appropriate in 65.0% of prescriptions, inappropriate in 12.5% (range across EDs: 0.6%-29.3%), and inconclusive in 22.5% (range across EDs: 0.4%-60.8%). Prescriptions were of inappropriate duration in 20% of oral prescriptions (range across EDs: 4.4%-59.0%). Oral prescriptions were not concordant with the local guideline in 22.3% (range across EDs: 11.8%-47.3%) of prescriptions in uncomplicated RTIs and in 45.1% (range across EDs: 11.1%-100%) of prescriptions in uncomplicated urinary tract infections. A limitation of our study is that the included EDs are not representative of all febrile children attending EDs in that country., Conclusions: In this study, we observed wide variation between European EDs in prescriptions of antibiotics and broad-spectrum antibiotics in febrile children. Overall, one-third of prescriptions were inappropriate or inconclusive, with marked variation between EDs. Until better diagnostics are available to accurately differentiate between bacterial and viral aetiologies, implementation of antimicrobial stewardship guidelines across Europe is necessary to limit antimicrobial resistance., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: MvdF received a grant from CSL Behring preclinical work immunoglobulin formulations; FS served on the scientific advisory board for Roche on Lyme disease serological diagnostics, received research support from the Slovenian Research Agency [grant number P3-0296], and is an unpaid member of the steering committee of the ESCMID Study Group on Lyme Borreliosis/ESGBOR. The other authors have declared that no competing interests exist.

In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: There is an increasing trend in using network science methods and algorithms, including community detection methods, in different areas of healthcare. These areas include protein networks, drug prescriptions, healthcare fraud detection, and drug abuse. Counterfeit drugs, off-label marketing issues, and finding the healthcare community structures in a network of hospitals, are examples of using community detection in healthcare., Objective: This paper attempts to find physicians' real medical specialties based on their prescription history. As a novel application of community detection in the healthcare field, this knowledge can be used as an alternative for missing values of the healthcare databases. Therefore, it could help scientists and researchers to obtain more accurate and more reliable results., Methods: This research is done through the community detection method and applying big data tools as well as interviews with the field experts. The big data, which is used in this paper, includes 32 million written medical prescriptions in the year 2014, provided by the Health Insurance Organization. The results are validated both qualitatively and quantitatively., Results: The findings reveal nine major communities of physicians, and labeling these communities by experts presents almost every specialty in the drug prescriptions field. Some of these communities are labeled as a single well-known specialty, and some others are consist of two or more specialties that have overlap with each other., Conclusion: After receiving the prescription data and getting the experts' opinions, it was revealed that some physicians might persistently prescribe drugs that are not in their fields of expertise. Regarding the accuracy of community detection and the use of existing data values, we proved this hypothesis., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The abuse of prescription opioid pain medication has contributed to the U.S. opioid crisis. Opioid stewardship programs ensure that our patients receive the safest and most effective opioid regimens. Opioid stewardship programs involve a multidisciplinary team, including pharmacists, orthopaedic surgeons, nurses, pain management personnel, and anesthesiologists. All of these stakeholders work together to formulate the best evidence-based use of these medications.

Background: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations., Materials and Methods: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription., Results: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001)., Conclusions: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia., (Published by Elsevier Inc.)

Purpose of Review: Glycopeptide antibiotics such as vancomycin are frequently utilized to treat resistant Gram-positive infections such as methicillin-resistant Staphylococcus aureus. The current literature on glycopeptide and lipoglycopeptide structure, hypersensitivity and potential cross-reactivity was reviewed, highlighting implications for safe prescribing., Recent Findings: Structurally similar, glycopeptides could theoretically cross-react. Immediate reactions to vancomycin include non-IgE-mediated reactions (e.g. red man syndrome) and IgE-mediated hypersensitivity (e.g. anaphylaxis), sharing clinical features. Vancomycin can activate mast cells via MAS-related G-protein-coupled receptor X2, an IgE-independent receptor implicated in non-IgE reactions. In-vivo and in-vitro testing for suspected IgE-mediated reactions to glycopeptides remain ill-defined. Vancomycin is increasingly recognized to cause severe cutaneous adverse reactions (SCAR), with drug reaction with eosinophilia and systemic symptoms (DRESS) predominantly reported. Vancomycin DRESS has been associated with HLA-A32:-01, with a number needed to prevent of 1 in 74. Data demonstrating cross-reactivity amongst glycopeptides and lipoglycopeptides is limited to case reports/series., Summary: Further studies and in-vivo/in-vitro diagnostics are required for better differentiation between IgE and non-IgE glycopeptide reactions. Despite its association with vanomycin DRESS, utility of pharmacogenomic screening for HLA-A32: 01 is ill-defined. Although HLA-A32:01 has been associated with vancomycin DRESS, its utility for pharmacogenomic screening is ill defined. Further clinical and immunological cross-reactivity data for glycopeptide/lipoglycopeptide antibiotics is required.

Aims : This study aimed to investigate the experiences of registered prescribers and their perceptions of the enablers and barriers to registered prescribing and the value of this fledgling role. Background : The role of prescribing has been extended to registered nurses in New Zealand. By adding the designated prescribing role to a nurse's role, their scope of practice expands and nurses are able to provide patients with holistic care while achieving greater independence and role satisfaction. Yet new nurse prescribers can experience anxiety and fear when confronted with the reality of the responsibility of prescribing. Methods : Sixteen semi-structured interviews were conducted with registered nurse prescribers across New Zealand. Data were analysed using a general inductive approach and thematic analysis utilised to identify themes and sub-themes. Results : Sixteen registered nurse prescribers participated in the study. Three main themes emerged with sub-themes: ability to expand practice, improving access to care, and importance of working in a collaborative team. Participants explained how they enjoyed the challenge and responsibility of the new prescribing role yet were frustrated with the realities of the restrictions of what they could actually prescribe and in some cases lack of role recognition. Registered nurse prescribing also improved access to care as nurses felt they provided more comprehensive care, resulting in reduced wait times, better continuity of care and a reduction in patient costs. The participants highlighted the importance of working in a collaborative team and believed their ability to prescribe maximised clinician time, however cautioned the need for on-going clinical mentorship and a prepared and supportive work environment. Conclusions : The addition of registered nurse prescribing provides a number of advantages to individual nurses in terms of career development and job satisfaction, and to patients and the health care system. The benefits to health care consumers and the health care system align directly to health care priorities of improving equity and access to care. Impact statement : Registered nurse prescribers perceive a number of advantages to the addition of prescribing to their own practice and benefits to patients and the health care system by enabling more accessible and cost-effective care.

Objective: Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)-based order set., Methods: Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission., Results: Analysis of 276 preorder set and 128 post-order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post-order set cohort. Variability between prescriptions and providers was significantly decreased in the post-order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified., Discussion: An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels., Implications for Practice: A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

Background: The use of antibiotics in the acute exacerbations of chronic obstructive pulmonary disease (COPD) remains controversial. Serum C-reactive protein (CRP), a sensitive biomarker for systemic inflammation and tissue damage, is a good indicator of lower respiratory tract bacterial infection. However, due to the small sample size of the existing studies, the clinical value of CRP in guiding the use of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) antibiotics is insufficient. The aim of this study was to evaluate the value of CRP-guided treatment strategies for AECOPD patients., Methods: This review summarizes and meta-analyses randomized controlled trials (RCTs) of CRP guiding antibiotic prescribing for COPD exacerbations. RCTs compare either usual-care or the GOLD strategy have been included. The following electronic databases have been searched: PubMed, Cochrane Library, Embase, CNKI, CBM, VIP, and Wanfang Data. The methodologic quality of RCTs has been assessed using the Cochrane risk assessment tool. All trials included are analyzed according to the criteria of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software, and GRADE pro GDT web solution are used for data synthesis and analysis., Results: This review evaluates the effects of CRP testing on the antibiotic use, CCQ, EQ-5D utility scores and adverse events in patients with COPD exacerbations., Conclusion: This review provides clear evidence that CRP testing can reduce the use of antibiotics in patients with AECOPD without causing harm.

Background: Uncontrolled blood pressure (BP) is an important modifiable risk factor for recurrent stroke. Secondary prevention measures when implemented can reduce stroke re-occurrence by 80%. However, hypertension control rates remain sub-optimal, and little data is available from primary care where most management occurs. The aim of this study was to describe BP control in primary care-based patients with a previous stroke or transient ischaemic attack (TIA) in Ireland, and to concurrently examine antihypertensive medication-dosing., Methods: Study participants most recent office-based BP reading was compared with the NICE (NG136) and European Society of Hypertension/ European Society of Cardiology (ESH/ESC 2013) goal of BP < 140/90 mmHg. Optimal anti-hypertensive medication dosing was determined by benchmarking prescribed doses for each drug with the World Health Organisation-Defined Daily Dosing (WHO-DDD) recommendations., Results: We identified 328 patients with a previous stroke or TIA in 10 practices. Blood pressure was controlled in almost two thirds of patients when measured against the ESH/ESC and NICE guidelines (63.1%, n = 207). Of those with BP ≥140/90 (n = 116), just under half (n = 44, 47.3%) were adequately dosed in all anti-hypertensive medications when compared with the WHO-DDD recommendations., Conclusion: Blood pressure control in patients post stroke/TIA appears sub-optimal in over one third of patients. A comparison of drug doses with WHO-DDD recommendations suggests that 47% of patients may benefit from drug-dose improvements. Further work is required to assess how best to manage blood pressure in patients with a previous stroke or TIA in Primary Care, as most consultations for hypertension take place in this setting.

The opioid crisis is a public health issue and has been linked to physician overprescribing. Pain management after thoracic surgery is not standardized at many centers, and we hypothesized that excessive narcotics were being dispensed on discharge. As a quality improvement initiative, we sought to understand current prescribing practices to better align the amount of opioids dispensed on discharge to actual patient needs. This was a single-center, retrospective review of patients undergoing thoracic surgery from 7/2015 to 7/2018. Demographics, operative data, perioperative pain medication use, and discharge pain medication prescriptions were analyzed. Opioids were converted to Morphine Milligram Equivalents (MME). Among 124 patients, 103 (83%) received intraoperative nerve blocks and 106 (85.5%) used PCAs. Prescribed MME/day at discharge were significantly higher than MME/day received during hospitalization (Median 30 [IQR 30-45] vs. 15 [IQR 5-24], p < 0.001) and were not associated with receiving a nerve block or PCA. By procedure, prescribed MME/day were significantly higher than inpatient MME/day for wedge resections (p < 0.001), segmentectomies (p = 0.02), lobectomies (p = 0.003), and thymectomies (p = 0.02). Patients are being discharged with significantly more opioids than they are using as inpatients. Education among prescribers and a standardized approach with patient-specific dosing may reduce excessive opioid dispensing.

BackgroundIn most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level.AimOur objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs' performance scores and their clinimetric properties using a large regional reimbursement database.MethodsA recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties).ResultsThe 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential.ConclusionsThe set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

Background and Purpose: To describe the design, implementation, and evaluation of systematic progressive community pharmacy-based prescription verification activities across a skills-based laboratory course series., Educational Activity and Setting: Community pharmacy-based prescription verification activities were implemented into three laboratory courses, Abilities Lab (ABL) 1, 2, and 4. During each activity, students practiced prescription verification using a handout with two components. First, a checklist outlining an eight-step verification process serves as a student resource. In the second handout component, students are required to identify which step contains a prescription error(s), the appropriate pharmacist action, and the recommendation needed in order to correct the error(s). After verifying and completing the handout, the students participate in a facilitator-led discussion on the recommendations necessary to dispense the prescription. As students progressed through ABL 1, 2, and 4, both the error type and scope of the verification process expanded. Class verification exercises culminated in a final practical assessment at the end of each semester., Findings: In ABL 1 students scored an average of 99.5% (n = 161, standard deviation (SD) = 1.92) on the final practical assessment. In ABL 2, students scored an average of 97.6% (n = 166, SD = 3.07). In ABL 4, students scored an average of 90.3% (n = 159, SD = 11.2)., Summary: This manuscript adds value to the current literature by describing the implementation of progressive community pharmacy-based prescription verification activities across a skills-based laboratory course series., Competing Interests: Declaration of competing interest None., (Published by Elsevier Inc.)

Background: Geriatric patients are the main users of medicinal products, although this patient group is most commonly excluded from clinical trials. Several guidelines from the International Conference on Harmonisation (ICH) and the European Medicines Agency (EMA) have tried to ensure the development and the safe use of medicines for geriatric patients., Objective: This article aims to evaluate geriatric information provided by the summary of product characteristics (SmPC) to prescribers using relevant medicinal products in Germany for patients older than 65 years., Material and Methods: Based on the annually published drug prescription report (Arzneiverordnungsreport), medication which was prescribed mainly (above 80%) or at a high defined daily dose (DDD [doses per day] > 400) to patients older than 65 years in 2016 was reviewed regarding relevant geriatric information., Results: The average compliance for the investigated drugs regarding geriatric information according to EMA guidelines is 27%. At least older patients are mentioned in the SmPC most frequently (68%). Information about doses or dose adjustments for patients with certain stages of frailty was not provided by the pharmaceutical companies., Conclusion: Current information in the SmPC for a safe and effective use of medicines for older patients is insufficient and does not conform to EMA guidelines. Compared to drug authorization in pediatrics where the industry is obliged to submit a special pediatric investigation plan (PIP) to cover the needs of this certain patient group, a mandatory geriatric investigation plan (GIP) similar to the PIP would be an appropriate measure to provide safe and effective medicines for older patients.

Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.

Background: United Kingdom legislation allows nurses to autonomously provide medications as independent nurse prescribers or using patient group directions. Evidence of medication safety and appropriateness is limited. We compared nurse prescribers and patient group direction users in terms of prevalence, types and severity of medication provision errors., Methods: Objectives: Compare safety and appropriateness of medication provision between nurse prescribers and patient group direction users., Design: MIXED METHODS: clinical notes review and nurse-patient consultation observations., Setting: Five United Kingdom sexual health services., Selection Criteria: 'Clinical notes review' included a random selection of nurse-patient consultations July-December 2015, 743 consultations managed by nurse prescribers and 939 consultations by patient group direction users. 'Observation study' involved 15 nurse prescriber and 15 patient group direction user nurse-patient medication consultations. Patients aged under 16 or non-English speaking were excluded., Measurements: Medication safety/appropriateness was compared between nurse prescribers and patient group direction users. Medication provision errors were categorised and assigned severity ratings. The Medication Appropriateness Index and the Prescribing Framework were used to assess medication provision., Results: Of 1682 clinical notes (nurse prescribers=743, 44%; patient group directions=939, 56%), 879 involved the provision of 1357 medications (nurse prescribers=399, 54%; patient group directions=480, 51%). The overall error rate was 8.5% (1844 errors from a potential 21,738 errors), predominantly related to documentation omissions. Nurse prescribers were more likely to make an error compared to patient group directions users (error rates 9% versus 8%, respectively; p=0.001); most were 'minor' (nurse prescribers=489, 56%; patient group directions=602, 62%). Both nurse prescribers and patient group direction users made safe medication decisions (n=1640 of 1682 patient care episodes, 98%); however, patient group directions users worked outside patient group directions restrictions in 39 (8%) of consultations. In 101 consultations, medication was indicated but not documented as offered/provided. From 30 observed consultations assessed against the Prescribing Framework, nurse prescribers' and patient group directions users' clinical practice were comparable (maximum score 46: nurse prescribers=44.7; patient group direction=45.4, p=0.41)., Conclusion: Sexual health nurse prescribers and patient group direction users provided safe and therapeutically appropriate medication. Improvements in clinical documentation are recommended. Moreover, patient group directions users should be encouraged to adhere to patient group directions' governance restrictions, such as through regular training, audits and staff updates., Competing Interests: Conflict of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Adam Black, Molly Courtenay, Heather Gage, Christine Norton, Trevor Murrells: None declared. Bryony Dean Franklin: has received two honoraria from Pfizer for organising and chairing medication safety educational events. Not directly linked to this study., (Copyright © 2020. Published by Elsevier Ltd.)

Disclosures: No funding supported the writing of this article. The author has nothing to disclose.

Objectives: Appropriate antibiotic prescriptions for outpatients with acute respiratory tract infections (ARTIs) are urgently needed in Japan. However, the empirical proof of this need is under-documented. Therefore, we aimed to determine antibiotic prescription rates, and the proportions of antibiotic classes prescribed for Japanese patients with ARTIs., Methods: We analysed health insurance claims data over 2013-2015 among Japanese patients aged <75 years and determined the following indicators: 1) visit rates for patients with ARTIs and antibiotic prescription rates per 1000 person-years, and 2) proportion of visits by antibiotic-prescribed patients with ARTIs. We defined broad-spectrum antibiotics using the WHO Anatomical Therapeutic Chemical classification 4 level codes., Results: Among 8.65 million visits due to ARTIs at 6859 hospitals and 62,024 physicians' offices, the visit rate and antibiotic prescription rate per 1000 person-years were 990.6 (99% confidence interval [CI], 989.4-991.7) and 532.4 (99% CI, 531.6-533.3), respectively. The visit rates for patients aged 0-17, 18-59, and 60-74 years were 2410.0 (99% CI, 2407.2-2412.9), 683.6 (99% CI, 682.7-684.6), and 682.1 (99% CI, 678.2-686.0), and antibiotic prescription rates were 1093.3 (99% CI, 1091.4-1095.2), 434.1 (99% CI, 433.4-434.9), and 353.4 (99% CI, 350.7-356.1), respectively. The overall proportion of antibiotic prescriptions for ARTI visits was 52.7% and 91.3% of the antibiotics prescribed were broad-spectrum., Conclusions: Both the visit rates and antibiotic prescription rates for ARTIs were high in this Japanese cohort. The proportion of antibiotic prescriptions exceeded that recommended in the clinical guidelines. Thus, there might be a scope for reducing the current antibiotic prescription rate in Japan., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: Limited evidence suggests integration of pharmacists into the general practice team could improve medicines management for patients, particularly those with multimorbidity and polypharmacy. This study aimed to develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland., Design: Non-randomised pilot study., Setting: Primary care in Ireland., Participants: Four general practices, purposively sampled and recruited to reflect a range of practice sizes and demographic profiles., Intervention: A pharmacist joined the practice team for 6 months (10 hours/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education., Outcome Measures: Anonymised practice-level medication (eg, medication changes) and cost data were collected. Patient-reported outcome measure (PROM) data were collected on a subset of older adults (aged ≥65 years) with polypharmacy using patient questionnaires, before and 6 weeks after medication review by the pharmacist., Results: Across four practices, 786 patients were identified as having 1521 prescribing issues by the pharmacists. Issues relating to deprescribing medications were addressed most often by the prescriber (59.8%), compared with cost-related issues (5.8%). Medication changes made during the study equated to approximately €57 000 in cost savings assuming they persisted for 12 months. Ninety-six patients aged ≥65 years with polypharmacy were recruited from the four practices for PROM data collection and 64 (66.7%) were followed up. There were no changes in patients' treatment burden or attitudes to deprescribing following medication review, and there were conflicting changes in patients' self-reported quality of life., Conclusions: This non-randomised pilot study demonstrated that an intervention involving pharmacists, working within general practices is feasible to implement and has potential to improve prescribing quality. This study provides rationale to conduct a randomised controlled trial to evaluate the clinical and cost-effectiveness of this intervention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Incompleteness and illegibility of prescriptions are prescription errors that account for a high proportion of medication errors that could potentially result in serious adverse effects. Thus, the objective of this study was to assess the completeness and legibility of prescriptions filled in the community chain pharmacies., Methods: An analytical and cross-sectional study was conducted in the six government owned community chain pharmacies of Asmara, Eritrea from June 3rd to 10th, 2019 using a stratified random sampling technique. A total of 385 prescriptions were analyzed for completeness and legibility by three pharmacists (two experienced and one intern pharmacist). Descriptive statistics and multinomial logistic regression were employed using IBM SPSS® (Version 22)., Results: A total of 710 drugs were prescribed from the 385 prescriptions assessed. On average, a prescription was found to have 78.63% overall completeness. In the majority of the prescriptions, patient's information such as name, age, sex, and prescriber's identity were present. Prescribed drugs' information such as dose, frequency and quantity and/or duration were present in 83.7, 87.7, and 95.1% respectively. Moreover, generic names were used in 83.3% of the drugs prescribed. About half (54.3%) of the prescriptions' legibility were classified in grade four (clearly legible) and 30.6% in grade three (moderately legible). It was observed that legibility significantly increased with an increase in percentage completeness (r s  = 0.14, p = 0.006). However, as the number of drugs written in brand name increased, legibility decreased (r s  = - 0.193, p < 0.001). Similarly, as the number of drugs prescribed increased, legibility decreased (r s  = - 0.226, p < 0.006)., Conclusion: Majority of the handwritten prescriptions received in the community pharmacies of Asmara are complete and clearly legible.

Background: Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors., Objective: We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S., Design: We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems., Participants: Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated., Approach: Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation., Key Results: Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery., Conclusions: Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs., Competing Interests: The authors have declared that no competing interests exist.

For most chronic medical conditions, multiple medications are available and prescribers often have limited evidence about which therapy is likely to be the most effective and safe for an individual patient. As many patients are exposed every day to medicines that may be less effective than available alternatives, this is of public health importance. Cluster randomised trials of prescribing policy offer an opportunity to rapidly obtain evidence of comparative effectiveness and safety. These trials can pose a low risk to patients and cause minimal disruption to usual care. Despite the potential scientific value of this approach, there remain valid concerns about consent, medication switching and the use of routinely collected data in research. We discuss these concerns with reference to an ongoing pilot study (Evaluating Diuretics in Normal Care (EVIDENCE) - a cluster randomised evaluation of hypertension prescribing policy, ISRCTN 46635087, registered 11 August 2017).

With the exception of a few medical specialties, the implementation of pharmacogenetic tests in daily practice has thus far been limited. The Royal Dutch Pharmacists Association (KNMP) has developed pharmacogenetics-based therapeutic doserecommendations for 80 medicinal product combinations on the basis of a systematic literature review. Genotyping of patients can take place on a reactive or pre-emptive basis; the advantage of pre-emptive genotyping is that it provides genetic information the moment a medicinal product is prescribed. Clinical decision support software is crucial to implement pharmacogenetics into daily practice.

Introduction: Prescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives., Methods: All prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason's Model of Accident Causation., Results: 330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber., Discussion: This study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Pharmacists' scope of practice has expanded in several states to include independently prescribing and dispensing hormonal contraceptive products. The objective of this research was to assess student knowledge and confidence with prescribing hormonal contraception following a simulated patient case activity., Methods: This was a descriptive, exploratory, nonexperimental study utilizing educational assessments and survey data from second professional year students during the 2017 to 2018 and 2018 to 2019 academic years. Student performance was assessed using a five-question readiness assurance test at the beginning of class, documented patient assessment and plan, and five-question post-activity quiz. Student confidence with interpreting legal regulations and following protocol instructions, performing a patient assessment, prescribing an appropriate contraceptive product, and providing verbal and written communication to patients and providers was assessed using a nine-question survey at the end of class., Results: Average student performance was consistent on the readiness assurance test between the two years. Students scored an average of 84.2% and 91.6% on the documented assessment and plan and 96.4% and 91.2% on the post-activity quiz for each year, respectively. Students felt most confident with navigating and interpreting a prescription drug formulary, providing the patient with written documentation, and communicating with the patient's prescriber. Students were less confident with selecting an appropriate product based on patient-specific factors and providing education on missed doses., Conclusions: This case-based activity demonstrated student knowledge and confidence with prescribing hormonal contraceptives., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.