Introduction: Chronic non-malignant pain poses considerable risk to patients and the health service but its management is still inadequate. The introduction of prescribing for nurses and pharmacists suggests that non-medical prescribing can improve some important aspects of healthcare services. Aim: To provide new insights and theory regarding how nurses and pharmacists prescribe for chronic pain, together with how the service is perceived by chronic pain patients and to uncover barriers and facilitators encountered when this group is prescribed for. Method: A mixed methods strategy was employed in this study. A grounded theory approach was used to collect data from non-medical prescribers and patients. Non-medical prescribes were then surveyed to confirm the emerging theory and determine barriers and facilitators. Findings: The theory ‘safety and support within the prescribing environment’ explains the relationship that non-medical prescribers have with colleagues, patients and other factors in their prescribing environment in their prescribing for chronic pain. Non-medical prescribers are motivated by various factors and may adopt an innovative or conservative approach in their prescribing. Nurses were more likely to engage in informal mentoring relationships, but were limited by their lack of medication knowledge. Pharmacists were limited by a lack of experience with patients, inaccessibility to formal CPD in paid work time and the threats introduced by concerns around ‘second checking'. Chronic pain patients had strategies to maintain relationships with their prescribers and this relationship influenced the likelihood of considering other measures to cope with their pain. Conclusion: Nurses and pharmacists who qualified as prescribers would be more likely to prescribe for chronic pain if they perceived certain essential elements in their prescribing environment. This theory can facilitate assessment of non-medical prescribers’ support, involvement of patients and the development of resources to encourage prescribing.

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No description available.

Objective: This study analysed the problems encountered by novice nursing students during the process of learning medication dosage calculation skills via didactic transmission methods and 'word problems'. Subsequently constructivist approaches were applied to the design and development of a computer-based 'Authentic World' learning environment. The relationship between exposure to these two teaching methods and the learning of dosage calculation skills, was evaluated in both college- and clinical-based environments. Participants and Setting : 44 novice nursing students following a pre-registration HE Diploma in Nursing Studies programme, within a large UK school of nursing. Design : During the college based phase of the investigation, two groups of 22 participants were exposed to a 'cross-over' experimental approach, involving: a) tuition via transmission and 'Authentic World' methods, followed by a written dosage calculation assessment. b) cross-over to the alternative treatment, followed by a written dosage calculation assessment. During the clinical-based phase of the investigation, a nine participant sub-sample were assessed during dosage calculation situations within child, adult and mental health care settings. A thematic analysis of post-assessment interviews was performed to identify participants' perceptions of the efficacy of the teaching strategies in assisting to bridge the theory-practice divide. Findings : Evaluations of participants' performance during written assessments revealed three error types: conceptual, arithmetical operation and computation errors. Findings indicated that exposure to the 'Authentic World' environment, assisted participants to develop accurate schema for understanding dosage problems and eliminated all conceptual errors. Development of schema for arithmetical operation and computation skills took a more protracted period of time. On completion of the college-based phase 80% of participants scored 100% on the written assessment, and performance on the written assessments proved to be predictive of dosage calculation performance in clinical practice. Conclusions: These results suggest that exposure to constructivist approaches assist novice nursing students to both develop requisite schema and understanding of medication dosage problems, and to bridge the theory-practice divide in this area of practice. Development of schema for arithmetical operation and computation methods requires a more protracted time period for assimilation and accommodation to occur. Implications for practice : The predictive nature of this education process assists learners scoring 100% on written assessments to enter clinical practice as advanced beginners in this domain; and enables early mobilisation of college support mechanisms to assist learners who manifest arithmetical operation and computation errors, to develop accurate schema for these skills.

Background: Inappropriate prescribing (IP) for older people is a public health concern worldwide because of its implications for increased healthcare costs and adverse drug events (ADE). Care home residents are particularly prone to IP due to intrinsic (frailty) and extrinsic (governance and management of homes) factors. My PhD focussed on prescribing for this vulnerable population. Methods: I conducted two systematic reviews which were aimed at: 1) establishing an IP-ADE link; and 2) interpreting interventions employed to reduce IP. Additionally, I evaluated the effectiveness of a multidisciplinary intervention in reducing IP in two nursing homes (combined sample size of 143 residents) managed by one general practice. In this multidisciplinary intervention, feedback from both a pharmacist medication review and an audit using STOPP (Screening Tool of Older Person's Prescriptions) which identified potentially inappropriate medication (PIM) and START (Screening Tool to Alert doctors to Right Treatment) which identified potential prescribing omission (PPO) were utilised by two general practitioners (GPs) to make appropriate changes to prescriptions. I compared the pre and post-intervention scores for PIMs and PPOs. Finally, I provided recommendations to improve overall prescribing quality in UK care homes. Main findings: The findings include: 1) Evidence for a correlation between IP and ADE was weak; 2) Interventions involving academic detailing, pharmacist medication review and multidisciplinary team meetings were more successful; 3) After the 13 months study, residents in the post-intervention group were significantly less likely to have been prescribed a PIM (RR 0.52, 95% CI 0.41-0.67) or a PPO (RR 0.58, 95% CI 0.48-0.69) as compared to residents in the pre-group. Factors influencing the number of PIMs and PPOs were number of medications and number of comorbidities respectively; 4) Recommendations for improving prescribing quality were broadly categorised into five areas: future research; legislation and directives; education and training; integrated healthcare services; and information technology. Conclusion: The multidisciplinary pharmacist-GP-researcher intervention is an effective and practical approach to reducing IP for nursing home residents.

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Chief pharmacists in 209 hospitals were surveyed about ADR reporting schemes, the priority given to ADR reporting, and attitudes towards ADR reporting. ADR reporting had a low managerial priority. Local reporting schemes were found to be operating in 37% trusts, but there were few plans to start new schemes. Few problems were discovered by the introduction of pharmacist ADR reporting. Chief pharmacists had concerns about the competence of hospital pharmacists to detect ADRs and were in favour of increased training. Lack of time on wards, and recruitment difficulties were suggested as reasons for hospital pharmacist under-reporting. Teaching hospitals appeared to have an increased interest in ADR reporting. A retrospective analysis of reporting trends within the West Midlands region from 1994, showed increasing or stable reporting rates for most sectors of reporters, except for general practitioners (GPs). The West Midlands region maintained higher ADR reporting rates than the rest of the UK. National reporting figures showed a worrying decline in ADR reports from healthcare professionals. Variation was found in the ADR reporting rates of Acute NHS Hospital Trusts and Primary Care Trusts (PCTs) in the West Midlands region, including correlations with prescribing rates and other PCT characteristics. Qualitative research into attitudes of GPs towards the Yellow Card scheme was undertaken. A series of qualitative interviews with GPs discovered barriers and positive motivators for their involvement in the Yellow Card scheme. A grounded theory of GP involvement in the Yellow Card scheme was developed to explain GP behaviour, and which could be used to inform potential solutions to halt declining rates of reporting. Under-reporting of ADRs continues to be a major concern to those who administer spontaneous reporting schemes.

Η υπέρταση είναι μία από τις πιο διαδεδομένες νόσους του σύγχρονου κόσμου. Υπολογίζεται ότι το 25% του ενήλικου πληθυσμού πάσχει από υπέρταση, ενώ μόλις το 11% των νοσούντων λαμβάνει κανονικά αντιυπερτασική αγωγή και έχει ρυθμίσει την αρτηριακή του πίεση στα επιθυμητά επίπεδα. Η εμφάνιση υπέρτασης είναι πολυπαραγοντικό φαινόμενο, και πολλές φορές η υπέρταση είναι σύμπτωμα άλλων υπαρχόντων νοσημάτων. Ωστόσο η αντιμετώπιση της πρέπει να είναι άμεση και αποτελεσματική, καθώς η αυξημένη πίεση του αίματος ενέχει άμεσα τον κίνδυνο εμφάνισης καρδιαγγειακού επεισοδίου με δυσάρεστες πολλές φορές συνέπειες. Σύμφωνα λοιπόν με αυτά τα δεδομένα είναι λογικό η αγορά των ανιυπερτασικών φαρμάκων να εμφανίζει μεγάλη ανάπτυξη και κατά συνέπεια ισχυρό ανταγωνισμό. Ενδεικτικά αναφέρουμε ότι από 1999 έως το 2003, η αγορά διπλασίασε τις πωλήσεις της σε €, ενώ υπάρχουν πολλές διαφορετικές κατηγορίες αντιυπερτασικών σκευασμάτων, που καθεμία έχει πολλά διαφορετικά πρότυπα και πολλά generic. φάρμακα και συνολικά ανταγωνίζονται σε αυτήν πάνω από 200 αντιυπερτασικά ιδιοσκευάσματα. Επίσης η αγορά αυτή εμφανίζει μεγάλη δυναμικότητα αφού ο ρυθμός ανανέωσής της με νέα σκευάσματα είναι μεγάλος. Στην έρευνα που πραγματοποιήθηκε προσπαθήσαμε να αποτυπώσουμε την άποψη των γιατρών για τις κατηγορίες των αντιυπερτασικών σκευασμάτων και να διερευνήσουμε τους λόγους που τους ωθούν να συνταγογραφήσουν ένα αντιυπερτασικό σκεύασμα έναντι ενός άλλου. Λαμβάνοντας υπόψη το γεγονός ότι οι δύο ειδικότητες των γιατρών που κατά κύριο λόγο εμπλέκονται στην αντιμετώπιση της υπέρτασης, είναι οι καρδιολόγοι και οι παθολόγοι προσπαθήσαμε να διερευνήσουμε αν υπάρχουν διαφορές στην συνταγογράφηση των ειδικοτήτων αυτών και αν υπάρχει διαφοροποίηση στους παράγοντες που τους ωθούν να συνταγογραφήσουν ένα σκεύασμα έναντι ενός άλλου. Από τα αποτελέσματα φάνηκε ξεκάθαρα η προτίμηση των γιατρών στους ΑΜΕΑ και στους Ανταγωνιστές των Υποδοχέων της Αγγειοτενσίνης ΙΙ, καθώς και η σαφής προτίμηση των καρδιολόγων στους ελεύθερους συνδυασμούς και των παθολόγων στους σταθερούς. Επίσης φάνηκε ότι η τιμή του φαρμάκου και κατ’ επέκταση το κόστος της συνταγής δεν αποτελεί ακόμη στην Ελλάδα σημαντικό κριτήριο που θα επηρεάσει την συνταγογράφηση των φαρμάκων, εν αντιθέσει με την τεκμηρίωση των κλινικών μελετών που σε συνδυασμό με την ιατρική ενημέρωση φαίνεται να παίζουν σημαντικό ρόλο. Αναφορικά με την διαφοροποίηση ανάμεσα σε καρδιολόγους και παθολόγους φάνηκε ότι τελευταίοι είναι πιο ευαισθητοποιημένοι πάνω στους παράγοντες που αφορούν την συμμόρφωση του ασθενούς και την αποτελεσματικότητα της θεραπείας. Ωστόσο η έρευνα αυτή είχε μάλλον ποιοτικό χαρακτήρα και υπάρχει ακόμα ευρύ πεδίο μελέτης πάνω στους παράγοντες που επηρεάζουν την συνταγογράφηση ώστε να μπορέσουμε να καταλήξουμε σε ποσοτικά συμπεράσματα, ενώ υπάρχει ακόμη και ένας πολύ μεγάλος αριθμός παραγόντων που μένει να αξιολογηθεί ποιοτικά και ποσοτικά. / Hypertension is one of the most common diseases of the modern world. It is estimated that 25% of the adult population suffers from hypertension, and only 11% of them receives proper antihypertensive therapy and has achieved desirable levels of blood pressure. The development of hypertension is often due to many different factors, sometimes being one of the symptoms of another disease. In any case, hypertension must be effectively treated/controlled, as it bears the risk of occurrence of cardiovascular incidents, with unpleasant consequences. As a result of these facts, the antihypertensive drugs market shows a considerable growth rate, and it in just 4 years (1999-2003) has doubled its sales. On the other hand, the various categories of antihypertensive agents –each one having many prototypes and generics- compete strongly for bigger market shares. Today more than 200 antihypertensive drugs constitute the ethical antihypertensive market. Furthermore, the renewal rate of this market is quite high. In this research we tried to trace doctors’ opinion of the different classes of antihypertensive drugs, and to investigate the reasons that make them prescribe one drug instead of another. Considering that the main specialties that are involved in the confrontation of hypertension are cardiologists and pathologists, we tried to explore if there are differences in the way the two specialties prescribe and to reveal possible differences among the reasons which affect them to choose one drug over another. The results clearly showed the preference of doctors to ACE Inhibitors and ARBs, and that cardiologists prefer to prescribe spare antihypertensive drugs in contrast to pathologists who prefer to prescribe antihypertensive drugs with fixed combinations of different antihypertensive agents. It was also shown, that the price of the drug, and furthermore the cost of the prescription is not a very important criterion for doctors to modify their prescriptional habits. As opposed to this, the results of the clinical trials of the drugs, as well as the incidence of the calls that medical representatives pay to the doctors, play an important role in the final choice of the doctor. Pathologists seemed to be more considerate than cardiologists about factors that had to do with patient compliance and effectiveness of the therapy. This research had only qualitative characteristics. There are many factors still to be explored in the field of elements that urge doctors to choose a certain drug over all others, and many parameters still to be found to quantitatively explain the prescriptional habits of doctors.

Les enfants diffèrent des adultes non seulement en termes de dimension corporelle mais aussi en termes physiologiques. En effet, les phénomènes de développement et maturation interviennent au cours de la croissance. Ces processus ne sont pas linéaires et induisent des différences pharmacocinétiques et pharmacodynamiques. Ainsi, contrairement à la pratique commune, il n’est pas approprié de déterminer les posologies pédiatriques directement à partir des doses adultes. Étudier la pharmacocinétique chez l’enfant est fondamental pour pouvoir déterminer les posologies à administrer. La méthodologie idéale est l’analyse de population à travers des modèles non-linéaires à effets mixtes. Cependant, même si cette méthode permet l’analyse de données éparses et déséquilibrées, le manque de données individuelles doit être compensé par l’inclusion de plus d’individus. Cela pose un problème lorsque l’indication du traitement est une maladie rare, comme le sont les syndromes épileptiques de l’enfance. Dans ce cas, l’extrapolation de modèles adultes à la population pédiatrique peut s’avérer avantageuse. L’objectif de ce travail de thèse était d’évaluer les recommandations posologiques d’antiépileptiques lorsque des données pharmacocinétiques pédiatriques sont suffisamment informatives pour permettre la construction d’un modèle, ou lorsque celles-ci ne sont pas suffisamment importantes ou ne peuvent pas être exploitées correctement. Dans un premier temps, un modèle parent-métabolite de l’oxcarbazépine et de son dérivé mono-hydroxylé (MHD) a été développé chez l’enfant épileptique âgé de 2 à 12 ans. Ce modèle a permis de mettre en évidence que les plus jeunes enfants nécessitent des doses plus élevées, ainsi que les patients co-traités avec des inducteurs enzymatiques. Un modèle a aussi été développé pour les enfants épileptiques de 1 à 18 ans traités avec la formulation de microsphères à libération prolongée d’acide valproïque. Ce modèle a tenu en compte le flip-flop associé à la formulation et la relation non-linéaire entre la clairance et la dose due à la liaison protéique saturable de façon mécanistique. Encore une fois, il a été mis en évidence le besoin de doses plus élevées pour les enfants plus jeunes. Puis, un modèle adulte du vigabatrin a été extrapolé à l’enfant pour déterminer les posologies permettant d’atteindre des expositions similaires à l’adulte pour traiter les épilepsies focales résistantes. A partir des résultats obtenus, qui sont en accord avec les conclusions d’essais cliniques, nous avons pu proposer une dose de maintenance idéale dans cette indication. Enfin, nous avons étudié la pertinence de l’extrapolation par allométrie théorique dans un contexte de non-linéarité avec l’exemple du stiripentol. Nous avons pu en conclure que cette méthode semble apporter de bonnes prédictions à partir de l’âge de 8 ans, contrairement aux molécules à élimination linéaire où cela semble correct à partir de 5 ans. En conclusion, nous avons pu tester et comparer différentes approches pour aider à la détermination de recommandations posologiques chez l’enfant. L’étude de la pharmacocinétique pédiatrique par des essais spécifiques reste indispensable au bon usage du médicament. / Children greatly differ from adults not only in terms of size but also in physiological terms. Indeed, developmental changes occur during growth due to maturation. These processes occur in a nonlinear fashion and can cause pharmacokinetic and pharmacodynamic differences. Thus, oppositely to common practice, it is not appropriate to scale pediatric doses directly and linearly from adults. The study of pharmacokinetics in children is then essential to determine those pediatric dosages. The more commonly used methodology is population analysis through non-linear mixed effects models. This method allows the analysis of sparse and unbalanced data. In return, the lack of individual data has to be balanced with the inclusion of more individuals. This can be a problem when the indication of treatment is a rare disease, as are epileptic syndromes of childhood. In this case, extrapolation of adult pharmacokinetic models to the pediatric population may be interesting. The objective of this thesis was to evaluate the dosage recommendations of antiepileptic drugs when pediatric pharmacokinetic data are sufficient to be modeled, and when they are not, extrapolating adequately adult information. Firstly, a parent-metabolite model of oxcarbazepine and its monohydroxy derivative (MHD) was developed in epileptic children aged 2 to 12 years. This model showed that younger children require higher doses, as well as patients co-treated with enzyme inducers. A model was also developed for epileptic children aged 1 to 18 years treated with a valproic acid sustained release microsphere formulation. This model took into account the flip-flop associated with the formulation and the non-linear relationship between clearance and dose caused by a saturable protein binding. Again, the need for higher doses for younger children was highlighted. Then, an adult model of vigabatrin was extrapolated to children to determine which doses allow to achieve exposures similar to adults in resistant focal onset seizures. From the results obtained, which are in agreement with the conclusions of clinical trials, we have been able to propose an ideal maintenance dose for this indication. Finally, we studied the relevance of extrapolation by theoretical allometry in a context of non-linearity with the example of stiripentol. We concluded that this method seems to provide good predictions from the age of 8, unlike the linear elimination molecules where it seems correct from 5 years. In conclusion, we were able to test and compare different approaches to help determine dosing recommendations in children. The study of pediatric pharmacokinetics in specific trials remains essential for the proper use of drugs.