Rational Prescribing

There is limited information on pediatric prescribing in Sierra Leone. This study evaluated prescribing patterns for under-five patients at Ola During Children's Hospital (ODCH) and assessed the extent of rational prescribing. A descriptive, cross-sectional, retrospective study of 294 prescriptions, selected by systematic random sampling was conducted at the outpatient department of ODCH. The World Health Organisation prescribing indicators were analyzed using the SPSS package 16.0. The index of rational drug prescribing (IRDP) was calculated to assess rational prescribing. The average number of medicines per prescription was 3.77. The percentage of medicines prescribed by generic names was 71.0%, while 74.8% and 21.1% of prescriptions had an antibiotic and injection, respectively. The percentage of medicines prescribed from the national essential medicines list was 70.6%. The most commonly prescribed pharmacological groups of medicines were vitamins (85.37%) and antibiotics (82...

Peresepan obat biasanya merupakan langkah terakhir dalam konsultasi pasien dan dokter. Obat yang diresepkan oleh dokter harus memenuhi kriteria peresepan obat yang rasional. Peresepan obat yang rasional memenuhi langkah proses pengambilan keputusan yang logis mulai dari pengumpulan data pasien melalui anamnesis, pemeriksaan fisik, pemeriksaan laboratorium atau penunjang lainnya. Dari situ dokter akan membuat hipotesis atau diagnosis kerja yang selanjutnya akan menuntun dia untuk menentukan langkah terapi yang diambil termasuk obat-obat yang akan diberikan ke pasien. Algoritma ini, sayangnya, tidak selalu terjadi dengan baik, sehingga terjadilah peresepan obat yang irasional. Penyebab hal ini multifaktor a.l. faktor dokter, faktor pasien dan juga faktor-faktor yang lebih tinggi misalnya aturan dan sistem pelayanan kesehatan yang tersedia di suatu wilayah atau negara. Atas latar belakang ini, World Health Organization (WHO) sejak tahun 90an telah memperkenalkan sistem pembelajaran yang dikembangkan terutama untuk mahasiswa kedokteran yaitu Guide to Good Prescribing. Makalah ini mendiskusikan latar-belakang dan isi metode Guide to Good Prescribing.

Peresepan obat biasanya merupakan langkah terakhir dalam konsultasi pasien dan dokter. Obat yang diresepkan oleh dokter harus memenuhi kriteria peresepan obat yang rasional. Peresepan obat yang rasional memenuhi langkah proses pengambilan keputusan yang logis mulai dari pengumpulan data pasien melalui anamnesis, pemeriksaan fisik, pemeriksaan laboratorium atau penunjang lainnya. Dari situ dokter akan membuat hipotesis atau diagnosis kerja yang selanjutnya akan menuntun dia untuk menentukan langkah terapi yang diambil termasuk obat-obat yang akan diberikan ke pasien. Algoritma ini, sayangnya, tidak selalu terjadi dengan baik, sehingga terjadilah peresepan obat yang irasional. Penyebab hal ini multifaktor a.l. faktor dokter, faktor pasien dan juga faktor-faktor yang lebih tinggi misalnya aturan dan sistem pelayanan kesehatan yang tersedia di suatu wilayah atau negara. Atas latar belakang ini, World Health Organization (WHO) sejak tahun 90an telah memperkenalkan sistem pembelajaran yang dikembangkan terutama untuk mahasiswa kedokteran yaitu Guide to Good Prescribing. Makalah ini mendiskusikan latar-belakang dan isi metode Guide to Good Prescribing.

Peresepan obat biasanya merupakan langkah terakhir dalam konsultasi pasien dan dokter. Obat yang diresepkan oleh dokter harus memenuhi kriteria peresepan obat yang rasional. Peresepan obat yang rasional memenuhi langkah proses pengambilan keputusan yang logis mulai dari pengumpulan data pasien melalui anamnesis, pemeriksaan fisik, pemeriksaan laboratorium atau penunjang lainnya. Dari situ dokter akan membuat hipotesis atau diagnosis kerja yang selanjutnya akan menuntun dia untuk menentukan langkah terapi yang diambil termasuk obat-obat yang akan diberikan ke pasien. Algoritma ini, sayangnya, tidak selalu terjadi dengan baik, sehingga terjadilah peresepan obat yang irasional. Penyebab hal ini multifaktor a.l. faktor dokter, faktor pasien dan juga faktor-faktor yang lebih tinggi misalnya aturan dan sistem pelayanan kesehatan yang tersedia di suatu wilayah atau negara. Atas latar belakang ini, World Health Organization (WHO) sejak tahun 90an telah memperkenalkan sistem pembelajaran yang dikembangkan terutama untuk mahasiswa kedokteran yaitu Guide to Good Prescribing. Makalah ini mendiskusikan latar-belakang dan isi metode Guide to Good Prescribing.

Prescription error is a common and preventable cause of adverse drug events and emerging as a public healthcare concern. It has been responsible for many morbidity, mortality, healthcare cost and litigations. Information regarding the pattern and the burden related to prescription error is limited in Saudi Arabia, particularly, in the Hail region. The study aims to identify the types and frequency of prescription errors in two major hospitals in the Hail Region, Saudi Arabia. A retrospective chart review of prescriptions issued over a two-month period (October-November 2014) was conducted using a validated form. Handwritten prescriptions from the outpatient clinic and Emergency Room were selected using simple random sampling and reviewed to identify any prescription error by two clinical pharmacists. A prescription error was defined and classified based on Neville's classification. Final data were analyzed using descriptive statistics. Data from 1000 prescriptions was extracted and reviewed. At least one prescription error was identified in all the prescriptions (100%). Type A errors identified were missing information related to dose (42%), diagnosis (47%), file number (78%), patient's body weight (100%) and age (63%). Of the 1000 prescriptions reviewed, 78% did not have a file number, 63% without the patient's name. Type D error was identified to be poor handwriting (28%), missing prescription date (34%), patient's sex (22%) and name (0.8%), prescribing date (34%), physician signature (27%) and stamp (16%). The frequency of prescription error at tertiary healthcare hospitals in the Hail Region, Saudi Arabia is high and preventable. Interventions to ensure adherence to good prescription practice, effective communication between healthcare professionals and computerized physician order entry are therefore needed to prevent the burden associated with the prescription error.

Background: Irrational use of medicines is a major problem worldwide. World health organization (WHO) estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately and that half of all patients fail to take them correctly. The overuse, under use or misuse of medicines results in wastage of scarce resources and widespread health hazards. Objective: To evaluate drug use according to core drug use indicators established by INRUD/WHO in Ethiopia. Methods: A prospective cross-sectional study technique using both qualitative and quantitative data collection methods were applied. All adult population that had a history of drug use were interviewed for qualitative analysis of data collection. For quantitative data, all prescribers and dispensers in Gondar were included. All the study data were analyzed using SPSS software. Results: A total of 322 participants were involved and 1430 prescriptions were collected and analyzed during the study period of one month from January to February 2013. 186(69.9%) of the patients understood the drug information were provided to them before dispensing, 23.7% got satisfaction with the counseling service provided by prescribers & dispensers, 51(19.1%) are not dared to ask health professionals for any drug information. In our study, 46.7% had financial problem to purchase the prescribed medication, 35.8% prematurely discontinued before finishing prescribed quantity, 115(43%) preferred parentral route over other routes. In addition 112(43.6%),104(40.5%) and 31(12.1%) of patient respondents said wastage of drug(or money), illness will not be improved, drug resistance respectively will occur by incomplete course of therapy. 51.5% prescribers prescribed at least one drug by brand name was observed during the study period. 63.6% of the prescriptions were from essential drug list. 36.4% dispense drugs without prescription, 86.4% have prepared prepackaging and labeling. 81.8% encountered a prescription out of normal range of dose with respect to age. The average number of drugs per encounter was 1.6 and 94.3% of drugs were prescribed by generic name. 78% of drugs were

The US healthcare industry emits an estimated 479 million tonnes of carbon dioxide each year; nearly 8% of the country’s total emissions. When assessed by sector, hospital care, clinical services, medical structures, and pharmaceuticals are the top emitters. For 15 years, research has been dedicated to the medical structures and equipment that contribute to carbon emissions. More recently, hospital care and clinical services have been examined. However, the carbon of pharmaceuticals is understudied. This article will focus on the carbon emissions of pharmaceuticals since they are consistently calculated to be among the top contributors to healthcare carbon and assess the factors that contribute to pharmaceutical carbon emissions. Specifically, overprescription, pharmaceutical waste, antibiotic resistance, routine prescriptions, non-adherence, drug dependency, lifestyle prescriptions, and drugs given due to a lack of preventive healthcare will be identified. Prescribing practices have environmental ramifications. Carbon reduction, when focused on pharmaceuticals, can lead to cleaner, more sustainable healthcare.

Like most elections of legislative bodies in the world, the election of the city council of Santa Cruz California needlessly wastes many citizens' votes. For example, its seven-member council was elected in 2018 and 2020 only by 46% of all citizens' votes cast, so 54% of the voters are not represented in the council. This means that any 4-to-3 majority decision in this council is only supported by a 26% minority of all the votes cast. This is not majority rule. All this waste and violation of the principle of majority rule can be removed with the help of a law like California's Voting Rights Act (CVRA). The CVRA aims to reduce, as much as possible, the number of votes wasted or "diluted." It requires elections to give "members of the electorate" an equal "opportunity ... to … elect representatives of their choice" (52 USC 10301)-including "voters who are members of a protected class" (CVRA 14027)-minorities of color or with a different first language.

Rational prescribing aims at improving the clinical condition, thereby improving the quality of life at affordable cost to the patient. Therefore it is important to know the pattern of drug prescribing in a particular set up. The present study was conducted with an objective to evaluate drug utilization pattern (DUP), at dental outpatient department of a teaching Institution, in south Delhi, India. The study design was prospective and cross sectional. Data from 1000 eligible dental prescriptions during consecutive 4 months was taken from September 2015-january 2016, as per ethical norms. Data was presented as tables and graphs. The prescriptions were analyzed using WHO core indicators. Out of 1000 dental prescriptions, 783 were having prescribed systemic medications. The average number of drugs per prescription was 2.89 and only 0.55% drugs were prescribed by generic name. The number of drugs given by injectable route was only 3%. Total number of prescriptions having antimicrobials were prescribed were (56%). The drugs prescribed from National essential medicine list (NEML) were 80%. We can conclude that there is a need to establish Drug and Therapeutic committees at dental hospitals and to sensitize dental practitioners for rational prescribing at affordable cost to patient. Polypharmacy and indiscriminate use of antimicrobials need to be minimized to prevent drug resistance. Continuing Medical Education (CMEs) and workshops should be conducted from time to time to create awareness regarding the rational use of drugs and to inculcate ethical etiquettes, not to indulge in malpractice.

The notion of repulsion plays a significant role in Stoic physiology and psychology, where it is analyzed as a dynamic of close interaction between imagination (phantasia) and corporeality, as well as in ethics and paedagogy. What characterizes the Stoic reflection on this particular theme is its systematic character and the structural position that repulsion assumes in the anthropological context. The repulsion plays firstly a decisive role in the cognitive development of the child, whose early experiences are not neutral but marked by both attractive and repulsive feelings. Accordingly, repulsion is a normative experience so that the content of the “repulsive” representation must be translated into linguistic terms and to give rise to a rule, precisely a prohibition.

Self-medication is widespread in Bangladesh and clinically inappropriate and inefficient use of medicines is a serious problem as a whole. Self-medication involves the use of medicine by the people who want to treat self-recognized symptoms by themselves. A cross sectional survey was conducted by 400 pre-tested and validated questionnaires distributed among the undergraduate students of similar age group and corresponding education level in Dhaka city. The survey was done simultaneously on 3rd year and 4th year medical students of Holy Family Red Crescent Medical College and Faculty of Business Administration in Green University, Dhaka during February to May 2016. To compare the knowledge, attitude and practice of self medication among the undergraduate students, medical and non-medical education had some impact in the responses. Undergraduate medical students were found to practice more self medication (78.1%) than the non-medical students (55.1%). Anti-pyretic or analgesics are the most common self-medication by medical students, whereas multivitamins are by non-medical students. The reasons behind the self medication was ‘minor illness’ (40%) and ‘confidence on self knowledge’ (33%) among the medical students; whereas the main reason among non-medical students was ‘need immediate relief’ (24%). Present study finds significant difference regarding self-medication antimicrobials and also with antiulcer drugs, cough-syrups, antipyretics, vitamins with minerals among the medical students of Bangladesh and West-Bengal. It may be due to lack of implementation of proper regulatory control on OTC sale of antimicrobials in Bangladesh.

Blocking acetylcholine transmission results in cellular events associated with neurodegenerative pathologies. This, along with results of animal studies and human observational studies, indicates that there is an urgent need to reduce anticholinergic (AC) drug use to minimize potential risks for dementia.

Abstract:
Continuing medical education (CME) is compulsory for physicians in Iran. Recent studies in Iran show that modifications of CME elements are necessary to improve the effectiveness of the educational programmes. Other studies point to an inappropriate, even irrational drug prescribing. Based on a needs assessment study regarding CME for general physicians in the East Azerbaijan province in Iran, rational prescribing practice was recognized as a high priority issue. Considering different educational methods, outcome-based education has been proposed as a suitable approach for CME. The purpose of the study was to obtain experts' consensus about appropriate educational outcomes of rational prescribing for general physicians in CME and developing curricular contents for this education.

METHODS:
The study consisted of two phases: The first phase was conducted using a two-round Delphi consensus process to identify the outcome-based educational indicators regarding rational prescribing for general physicians in primary care (GPs). In the second phase the agreed indicators were submitted to panels of experts for assessment and determination of content for a CME program in the field.

RESULTS:
Twenty one learning outcomes were identified through a modified Delphi process. The indicators were used by the panels of experts and six educational topics were determined for the CME programme and the curricular content of each was defined. The topics were 1) Principles of prescription writing, 2) Adverse drug reactions, 3) Drug interactions, 4) Injections, 5) Antibiotic therapy, and 6) Anti-inflammatory agents therapy. One of the topics was not directly related to any outcome, raising a question about the need for a discussion on constructive alignment.

CONCLUSIONS:
Consensus on learning outcomes was achieved and an educational guideline was designed. Before suggesting widespread use in the country the educational package should be tested in the CME context.

This research aimed to collect, for the first time, information about attitudes of Croatian psychologists toward prescribing. This study also addressed ethical dilemmas related to the possibility of obtaining prescriptive privileges and the current professional standards of practice in Croatia. The total sample was 139 psychologists (88% female). Sampling was via a closed Facebook group and with the help of the Croatian Psychological Association. A majority of respondents supported prescribing privileges for psychologists, and most would like to be educated to prescribe psychotropic medications. There were statistically significant differences between those who favored prescribing and those who opposed it on the topics of type of education, necessary knowledge, and arguments for prescribing. Socio-demographic factors did not influence attitudes toward prescribing. The strongest argument for prescribing was a possibility for the integration of psychotherapy and pharmacotherapy. However, the prevailing argument against was the fear of conflicts with physicians. There are ethical dilemmas regarding current education of psychologists in Croatia and their competence with regard to prescribing privileges.

Background The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and ...

There is limited information on pediatric prescribing in Sierra Leone. This study evaluated prescribing patterns for under-five patients at Ola During Children's Hospital (ODCH) and assessed the extent of rational prescribing. A descriptive, cross-sectional, retrospective study of 294 prescriptions, selected by systematic random sampling was conducted at the outpatient department of ODCH. The World Health Organisation prescribing indicators were analyzed using the SPSS package 16.0. The index of rational drug prescribing (IRDP) was calculated to assess rational prescribing. The average number of medicines per prescription was 3.77. The percentage of medicines prescribed by generic names was 71.0%, while 74.8% and 21.1% of prescriptions had an antibiotic and injection, respectively. The percentage of medicines prescribed from the national essential medicines list was 70.6%. The most commonly prescribed pharmacological groups of medicines were vitamins (85.37%) and antibiotics (82...

Context: Vietnam is one of the countries at the high alert of antibiotic resistance.

Aims: To evaluate the compliance rate and changes in physicians’ prescribing patterns in patients with community-acquired pneumonia (CAP) before and after using the antibiotic order form (AOF) in a tertiary hospital.

Methods: 120 inpatient medical records having antibiotic use and 115 patient medical records diagnosed with CAP at a Department of Respiratory Medicine during 3 months before and 3 months after using the AOF were retrospectively collected for assessment.

Results: The compliance rate was 92%, and the average rate of filling in information fields was 58%. Comparison of prescribing behavior of CAP in control and intervention group showed that the rate of bacterial culture increased from 70% to 77% (p = 0.690), in which the rate of culture prior prescribing administration increased from 14% to 45% (p < 0.001), the initial antibiotic regimen with narrow-spectrum increased from 26% to 36% (p = 0.353), the proportion of patients improved clinically after 72 hours increased from 64% to 89% (p = 0.138), and the de-escalation decreased from 23% to 20% (p = 0.713). The treatment failure at hospital discharge decreased from 12% to 6% (p = 0.447). However, the length of treatment and the days of antibiotic treatment were not significantly different.

Conclusions: The compliance rate was high, but the AOF filling rate was incomplete. Improving prescribing patterns and treatment efficacy in CAP patients is a suggestion to combine the AOF into multifaceted interventional efforts for specific patients.

Background: Continuing medical education (CME) is compulsory in Iran, and traditionally it is lecture-based, which is mostly not successful. Outcome-based education has been proposed for CME programs. Aim: To evaluate the effectiveness of an outcome-based educational intervention with a new approach based on outcomes and aligned teaching methods, on knowledge and skills of general physicians (GPs) working in primary care compared with a concurrent CME program in the field of ''Rational prescribing''. Method: The method used was cluster randomized controlled design. All GPs working in six cities in one province in Iran were invited to participate. The cities were matched and randomly divided into an intervention arm for education on rational prescribing with an outcome-based approach, and a control arm for a traditional program on the same topic. Knowledge and skills were assessed using a pre-and post-test, including case scenarios. Results: In total, 112 GPs participated. There were significant improvements in knowledge and prescribing skills after the training in the intervention arm as well as in comparison with the changes in the control arm. The overall intervention effect was 26 percentage units. Conclusion: The introduction of an outcome-based approach in CME appears to be effective when creating programs to improve GPs' knowledge and skills.

ABSTRACT Background: Irrational use of medicines is a major problem worldwide. World health organization (WHO) estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately and that half of all patients fail to take them correctly. The overuse, under use or misuse of medicines results in wastage of scarce resources and widespread health hazards. Objective: To evaluate drug use according to core drug use indicators established by INRUD/WHO in Ethiopia. Methods: A prospective cross-sectional study technique using both qualitative and quantitative data collection methods were applied. All adult population that had a history of drug use were interviewed for qualitative analysis of data collection. For quantitative data, all prescribers and dispensers in Gondar were included. All the study data were analyzed using SPSS software. Results: A total of 322 participants were involved and 1430 prescriptions were collected and analyzed during the study period of one month from January to February 2013. 186(69.9%) of the patients understood the drug information were provided to them before dispensing, 23.7% got satisfaction with the counseling service provided by prescribers &amp;amp; dispensers, 51(19.1%) are not dared to ask health professionals for any drug information. In our study, 46.7% had financial problem to purchase the prescribed medication, 35.8% prematurely discontinued before finishing prescribed quantity, 115(43%) preferred parentral route over other routes. In addition 112(43.6%),104(40.5%) and 31(12.1%) of patient respondents said wastage of drug(or money), illness will not be improved, drug resistance respectively will occur by incomplete course of therapy. 51.5% prescribers prescribed at least one drug by brand name was observed during the study period. 63.6% of the prescriptions were from essential drug list. 36.4% dispense drugs without prescription, 86.4% have prepared prepackaging and labeling. 81.8% encountered a prescription out of normal range of dose with respect to age. The average number of drugs per encounter was 1.6 and 94.3% of drugs were prescribed by generic name. 78% of drugs were actually dispensed and mean consultation and dispensing time was found to 4.13minutes. 77.4% of patient could adequately report the dosage schedule for all drugs. Conclusion: The overall results of our drug use evaluation study in the public facilities of Gondar city showed that there is a good availability of essential drugs and a high adherence of prescribers to drugs found in national drug list. While physician’s use of generic names was fairly high, efficiency was impaired by poor quality of pharmaceutical care, resulting in very low patient understanding.

use was in the East South-Central region (5.1%) [3]. Because CAM treatments, including deep breathing and meditation are relatively common in the United States, it is important for health care providers to have knowledge of how they are practiced and what their potential benefits are. There are several types of meditative practice, originating from different CAM systems. Mindfulness meditation (MM) is a contemporary form of meditation that stems from Buddhist traditions. Studies on the benefits of MM have demonstrated numerous benefits, including improving cardiovascular health. Mindfulness meditation is associated with lowered cardiovascular

Purpose: There is limited information on pediatric prescribing in Sierra Leone. This study evaluated prescribing patterns for under-five patients at Ola During Children's Hospital (ODCH) and assessed the extent of rational prescribing. Methods: A descriptive, cross-sectional, retrospective study of 294 prescriptions, selected by systematic random sampling was conducted at the outpatient department of ODCH. The World Health Organisation prescribing indicators were analyzed using the SPSS package 16.0. The index of rational drug prescribing (IRDP) was calculated to assess rational prescribing. Results: The average number of medicines per prescription was 3.77. The percentage of medicines prescribed by generic names was 71.0%, while 74.8% and 21.1% of prescriptions had an antibiotic and injection, respectively. The percentage of medicines prescribed from the national essential medicines list was 70.6%. The most commonly prescribed pharmacological groups of medicines were vitamins (85.37%) and antibiotics (82.99%). The IRDP was 2.71, instead of the ideal value of 5. Conclusion: Pediatric prescribing patterns at the outpatient department of ODCH cannot be said to be entirely rational, especially with regards to antibiotic and injection prescribing.

Background. There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs. Methods. Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors. Results. The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of "noninterference" in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a "prescribing etiquette," which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB. Conclusions. To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.

Background. There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs. Methods. Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors. Results. The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of "noninterference" in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a "prescribing etiquette," which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB. Conclusions. To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.

Inappropriate prescribing in primary care was implicated in nearly half of asthma deaths reviewed in the UK's recent National Review of Asthma Deaths. Using anonymised EMIS-Web data for 139 ethnically diverse general practices (total population 942,511) extracted from the North and East London Commissioning Support Unit, which holds hospital Secondary Uses Services (SUS)-linked data, we examined the prevalence of over-prescribing of short-acting β 2-agonist inhalers (SABA), under-prescribing of inhaled corticosteroid (ICS) inhalers and solo prescribing of long-acting β 2-agonists (LABA) to assess the risk of hospitalisation for people with asthma for 1 year ending August 2015. In a total asthma population of 35,864, multivariate analyses in adults showed that the risk of admission increased with greater prescription of SABA inhalers above a baseline of 1-3 (4-12 SABA: odds ratio (OR) 1.71; 95% confidence interval (CI) 1.20-2.46, ⩾ 13 SABA: OR 3.22; 95% CI 2.04-5.07) with increasing British Thoracic Society step (Step 3: OR 2.90; 95% CI 1.79-4.69, Step 4/5: OR 9.42; 95% CI 5.27-16.84), and among Black (OR 2.30; 95% CI 1.64-3.23) and south Asian adult populations (OR 1.83; 95% CI 1.36-2.47). Results in children were similar, but risk of hospitalisation was not related to ethnic group. There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year. Adults (but not children) from Black and South Asian groups are at an increased risk of admission. Further work is needed to target care for these at-risk groups.

Background Opioid analgesics are frequently initiated for chronic and acute pain despite weak evidence of benefit, although prescribing rates of some analgesics decreased in the context of the epidemic. In some populations, up to a quarter of opioid naïve persons prescribed opioids for non-cancer pain develop prescription opioid use disorder (OUD). Audit and feedback interventions rely on constructive use of routinely collected data to align professional behaviours and clinical practice with best evidence. These interventions have been shown to help reduce inappropriate initiation. However, effectiveness and acceptability of individualized "portraits" of physicians' prescribing patterns, to reduce inappropriate initiation of opioid analgesics to opioid naïve persons, have not been evaluated. Methods REDONNA is a mixed-methods randomized study testing the effectiveness of individualized prescribing Portraits to reduce inappropriate initiation of opioid analgesics. This intervention to improve safety of opioid prescribing in primary care in British Columbia (BC), Canada involves mailing individual prescribing portraits to an 'early group' of 2604 family physicians, followed in 6 months by a mailing to 2553 family physicians in the 'delayed group'. Primary outcome is number of new opioid prescriptions initiated in opioid naïve people, measured using administrative data from a centralized medication monitoring database covering all prescription opioids dispensed from BC community pharmacies. Secondary endpoints will compare prescribing impact between the two groups. A qualitative sub-study will examine feasibility among a purposive sample of physicians and patients. Discussion This trial provides important evidence on the intervention's potential to steer policy and practice on inappropriate opioid analgesics initiation. Trial registration: The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).

Objective: Infections caused by parasitic worms are among the most common diseases in the world. Considering the parasitic infections resistant to treatment, drug side effects and the emergence of new immunological diseases, it seems more necessary to pay attention to the views and therapeutic experiences of physicians in Iranian Traditional Medicine (ITM).
Methods: As A review study, data related to parasitic diseases and worms were first collected from Avicenna’s the Canon of Medicine book and other ITM books, and then underwent content analysis. Avicenna’s approach in the treatment of these diseases was studied based on the rational prescribing model.
Results: Avicenna’s approach in the treatment of parasitic diseases is based on problem-solving model and according to the summary of patients’ conditions in terms of disease severity and prioritization of causes. It varies from person to person.
Conclusion: Awareness of the causes of parasitic diseases, categorization of their clinical symptoms based on ITM, knowledge of natural and herbal medicine and various methods of prescribing them according to the health principals along with diagnostic and therapeutic methods of classic medicine can be helpful in control and prevention of parasitic diseases.

Background: Continuing medical education (CME) is compulsory for physicians in Iran. Recent studies in Iran show that modifications of CME elements are necessary to improve the effectiveness of the educational programmes. Other studies point to an inappropriate, even irrational drug prescribing. Based on a needs assessment study regarding CME for general physicians in the East Azerbaijan province in Iran, rational prescribing practice was recognized as a high priority issue. Considering different educational methods, outcome-based education has been proposed as a suitable approach for CME. The purpose of the study was to obtain experts' consensus about appropriate educational outcomes of rational prescribing for general physicians in CME and developing curricular contents for this education.