Peer assessment to improve medical student's contributions to team-based projects: randomised controlled trial and qualitative follow-up.

BACKGROUND: Medical schools increasingly incorporate teamwork in their curricula but medical students often have a negative perception of team projects, in particular when there is unequal participation. The purpose of this study is to evaluate whether a novel peer evaluation system improves teamwork contributions and reduces the risk of students "free loading". METHODS: A cluster randomised controlled trial (RCT) with qualitative follow up enrolled 37 teams (n = 223 students). Participating teams were randomised to intervention group (19 teams) or control group (18 teams). The validated Comprehensive Assessment Team Member Effectiveness (CATME) tool was used as the outcome measure, and was completed at baseline (week 2) and at the end of the project (week 10). The team contribution subscale was the primary outcome, with other subscales as secondary outcomes. Six focus group discussions were held with students to capture the team's experiences and perceptions of peer assessment and its effects on team work. RESULTS: The results of the RCT showed that there was no difference in team contribution, and other forms of team effectiveness, between intervention and control teams. The focus group discussions highlighted students' negative attitudes, and lack of implementation of this transparent, points-based peer assessment system, out of fear of future consequences for relationships with peers. The need to assess peers in a transparent way to stimulate open discussion was perceived as threatening by participants. Teams suggested that other peer assessment systems could work such as rewarding additional or floating marks to high performing team members. CONCLUSIONS: Other models of peer assessment need to be developed and tested that are non-threatening and that facilitate early acceptance of this mode of assessment.

'If you can't see a dilemma in this situation you should probably regard it as a warning': a metasynthesis and theoretical modelling of general practitioners' opioid prescription experiences in primary care.

INTRODUCTION: The prescribing of opioids has increased internationally in developed countries in recent decades within primary and secondary care. The majority of patients with chronic non-malignant pain (CNMP) are managed by their general practitioner (GP). Recent qualitative studies have examined the issue of opioid prescribing for CNMP from a GP viewpoint. The aim of this study is to identify and synthesise the qualitative literature describing the factors influencing the nature and extent of opioid prescribing by GPs for patients with CNMP in primary care. METHODS: MEDLINE, Embase, PsycINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986 to February 2018. The full text of included articles was reviewed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. The papers were coded by two researchers and themes organised using Thematic Network Analysis. Themes were constructed in a hierarchical manner, basic themes informed organising themes which informed global themes. A theoretical model was derived using global themes to explain the interplay between factors influencing opioid prescribing decisions. RESULTS: From 7020 records, 21 full text papers were assessed, and 13 studies included in the synthesis; 9 were from the United States, 3 from the United Kingdom and 1 from Canada. Four global themes emerged: suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision-making processes underlying opioid prescribing whereby the physician both consciously and unconsciously quantifies the risk-benefit relationship associated with initiating or continuing an opioid prescription. CONCLUSION: Recognising the inherent complexity of opioid prescribing and the limitations of healthcare systems is crucial to developing opioid stewardship strategies to combat the rise in opioid prescription morbidity and mortality.

Reviewing Competence in Practice: Reform of Continuing Professional Development for Irish Pharmacists.

There has been significant reform of the Continuing Professional Development (CPD) requirements for Irish pharmacists over the past five years. In 2015, a new system was established that includes quality assurance of practitioner engagement in CPD and quality assurance of practitioner competence. Pharmacists must now plan and document their learning activities in an electronic portfolio (ePortfolio) and they must participate in an ePortfolio Review process once every five-year period. A random sample is chosen each year to participate in a review of their practice for pharmacists in patient-facing roles. This paper provides an overview of the development and implementation of these quality assurance processes and it considers the outcomes that were observed in the first four years of implementation. By April 2019, almost 3000 pharmacists had participated in the ePortfolio Review process over the preceding three years, of which 96.2% demonstrated appropriate engagement in CPD. In the preceding two years, almost 200 pharmacists had participated in Practice Review, of which 97.5% have demonstrated the required level of competence across four competencies. All of the pharmacists who did not demonstrate the required level of competence in one or more competency area during Practice Review had previously demonstrated appropriate engagement in CPD through the ePortfolio Review process. This raises interesting questions regarding the use of engagement in continuing education (CE) or CPD as a surrogate measure for competence by professions.

Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study.

Background Analgesics are used in the management of chronic non-malignant pain (CNMP), a condition which is highly prevalent among older adults. CNMP may not only be physically distressing but also complicated by psychosocial and economic factors. An individual's perception and use of analgesics may be influenced by a range of factors such as perceptions of risk or benefits, ability to purchase medication or access to non-pharmacological therapies or specialist care. Objective The aim of this study was to describe the perceptions and experiences of analgesics by ageing and elderly individuals with CNMP and identify factors that influence their use. Setting Telephone interviews with 28 members of Chronic Pain Ireland aged ≥50. Method In-depth semi-structured interviews; audio-recorded, transcribed verbatim, and thematically analysed. Main outcome measure Experiences and perceptions of ageing and elderly individuals with CNMP taking analgesics. Results A combination of factors specific to the patient and arising from outside influences informed perceptions and experiences of analgesics. Pain severity, perceived efficacy of analgesics, occurrence of adverse-effects and concerns about addiction/dependence were identified as internal factors influencing medication use. External factors included views of family members, access to specialised care and the individual's interaction with healthcare professionals (HCPs). Conclusion Individuals with CNMP regard analgesics as an important method for managing pain and are relied upon when other interventions are difficult to access. HCPs in primary care, who are the main point of contact for patients, need to take into account the various factors that may influence analgesic use when consulting with this patient group.

Interventions to optimise prescribing for older people in care homes.

BACKGROUND: There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. This is an update of a previously published review (Alldred 2013). OBJECTIVES: The objective of the review was to determine the effect of interventions to optimise overall prescribing for older people living in care homes. SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Specialised Register), MEDLINE, EMBASE and CINAHL to May 2015. We also searched clinical trial registries for relevant studies. SELECTION CRITERIA: We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes: adverse drug events; hospital admissions; mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. We presented a narrative summary of results. MAIN RESULTS: The 12 included studies involved 10,953 residents in 355 (range 1 to 85) care homes in ten countries. Nine studies were cluster-randomised controlled trials and three studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of ten studies. Four studies involved multidisciplinary case-conferencing, five studies involved an educational element for health and care professionals and one study evaluated the use of clinical decision support technology. We did not combine the results in a meta-analysis due to heterogeneity across studies. Interventions to optimise prescribing may lead to fewer days in hospital (one study out of eight; low certainty evidence), a slower decline in health-related quality of life (one study out of two; low certainty evidence), the identification and resolution of medication-related problems (seven studies; low certainty evidence), and may lead to improved medication appropriateness (five studies out of five studies; low certainty evidence). We are uncertain whether the intervention improves/reduces medicine costs (five studies; very low certainty evidence) and it may make little or no difference on adverse drug events (two studies; low certainty evidence) or mortality (six studies; low certainty evidence). The risk of bias across studies was heterogeneous. AUTHORS' CONCLUSIONS: We could not draw robust conclusions from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems and improvements in medication appropriateness, however evidence of a consistent effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.

General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study.

Chronic non-malignant pain (CNMP) is commonly managed by General Practitioners (GPs) in primary care. Analgesics are the mainstay of CNMP management in this setting. Selection of medications by GPs may be influenced by micro factors which are relevant to the practice setting, meso factors which relate to the local or regional environment or macro factors such as those arising from national or international influences. The aim of this study is to explore influences on GP practises in relation to pain management for older adults with CNMP. Semi-structured interviews were conducted with 12 GPs. Transcripts were organised using the Framework Method of Data Management while an applied thematic analysis was used to identify the themes emerging from the data. Clinical considerations such as the efficacy of analgesics, adverse effects and co-morbidities strongly influence prescribing decisions. The GPs interviewed identified the lack of guidance on this subject in Ireland and described the impact of organisational and structural barriers of the Irish healthcare system on the management of CNMP. Changes in practice behaviours coupled with health system reforms are required to improve the quality and consistency of pharmacotherapeutic management of CNMP in primary care.

Potential for alcohol and drug interactions in older adults: evidence from the Irish longitudinal study on ageing.

BACKGROUND: Older adults are susceptible to adverse effects from the concomitant use of prescription medications and alcohol. This study estimates the prevalence of exposure to alcohol interactive (AI) medications and concomitant alcohol use by therapeutic class in a large, nationally representative sample of older adults. METHODS: Cross-sectional analysis of a population based sample of older Irish adults aged ≥60 years using data from The Irish Longitudinal Study on Ageing (TILDA) (N = 3,815). AI medications were identified using Stockley's Drug Interactions, the British National Formulary and the Irish Medicines Formulary. An in-home inventory of medications was used to characterise AI drug exposure by therapeutic class. Self-reported alcohol use was classified as non-drinker, light/moderate and heavy drinking. Comorbidities known to be exacerbated by alcohol were also recorded (diabetes mellitus, hypertension, peptic ulcer disease, liver disease, depression, gout or breast cancer), as well as sociodemographic and health factors. RESULTS: Seventy-two per cent of participants were exposed to AI medications, with greatest exposure to cardiovascular and CNS agents. Overall, 60% of participants exposed to AI medications reported concomitant alcohol use, compared with 69.5% of non-AI exposed people (p < 0.001). Almost 28% of those reporting anti-histamine use were identified as heavy drinkers. Similarly almost one in five, combined heavy drinking with anti-coagulants/anti-platelets and cardiovascular agents, with 16% combining heavy drinking with CNS agents. Multinomial logistic regression showed that being male, younger, urban dwelling, with higher levels of education and a history of smoking, were associated with an increased risk for concomitant exposure to alcohol consumption (both light/moderate and heavier) and AI medications. Current smokers and people with increasing co-morbidities were also at greatest risk for heavy drinking in combination with AI medications. CONCLUSIONS: The concurrent use of alcohol with AI medications, or with conditions known to be exacerbated by alcohol, is common among older Irish adults. Prescribers should be aware of potential interactions, and screen patients for alcohol use and provide warnings to minimize patient risk.

Frataxin acts as an iron chaperone protein to modulate mitochondrial aconitase activity.

Numerous degenerative disorders are associated with elevated levels of prooxidants and declines in mitochondrial aconitase activity. Deficiency in the mitochondrial iron-binding protein frataxin results in diminished activity of various mitochondrial iron-sulfur proteins including aconitase. We found that aconitase can undergo reversible citrate-dependent modulation in activity in response to pro-oxidants. Frataxin interacted with aconitase in a citrate-dependent fashion, reduced the level of oxidant-induced inactivation, and converted inactive [3Fe-4S]1+ enzyme to the active [4Fe-4S]2+ form of the protein. Thus, frataxin is an iron chaperone protein that protects the aconitase [4Fe-4S]2+ cluster from disassembly and promotes enzyme reactivation.