Decreasing the disparity between cervical cancer screening services provided and those recommended requires addressing the barriers, identified by local experts, which prevent uninsured women from accessing care. These challenges are being addressed through ongoing programs and collaborations.
IntroductionThis study explored the reflective writing (RW) of senior medical students across a co-ordinated reflection education programme in General Practice, Paediatrics and Psychiatry clerkships during their transition to clinical clerkships. The study compared RW themes from within and across three clerkships in order to understand the influence clerkships had on experiential learning and developing professional identity. MethodsAll medical students in their penultimate year were invited to participate in the study. 135 reflection assignments were analysed. A qualitative thematic analysis of students' RW was performed. An inductive approach was used and data saturation was achieved.
Study Objectives: Elderly patients represent a population at elevated risk for adverse drug events due not only to polypharmacy, but also to physiological changes that decrease metabolism and clearance of individual drugs. This risk is especially pronounced with regard to renally-cleared medications. Studies suggest emergency physicians inappropriately dose 24-46% of renally-cleared prescriptions, often requiring guidance from automated decision support tools or in-department pharmacists to adjust dosages appropriately. The purpose of this study was to analyze our prescribing patterns in an elderly emergency department (ED) population and to determine our accuracy in adjustment for renal impairment.Methods: This is a retrospective observational study conducted at 2 tertiary care EDs between April 15, 2017 -April 30, 2018. Inclusion criteria included all patients age 65 years or older who were discharged with a new prescription. Each new medication counted as one encounter. We sought to determine how many new discharge medications required adjustment for renal function. We then looked at a subset of anti-infective medications (oseltamivir, sulfamethoxazole-trimethoprim, and nitrofurantoin) to determine if ED physicians appropriately adjusted the medication dosage for renal function. Age, weight, serum creatinine and sex were used to calculate the estimated creatinine clearance (CrCl) in milliliters/minute (mL/min). Patients were excluded from final analysis if data was incomplete.Results: During the study period, there were 6674 prescriptions dispensed upon ED discharge, 1256 (19%) of these were for medications in which dosing for renal impairment is recommended. Among these, the majority were anti-infectives (920, 73.2%). The next most common were analgesics (152, 12.1%), anti-hypertensives (104, 8.2%), and anticoagulants (81, 6.4%). For the subset analysis, oseltamivir was dispensed 85 times. 25 prescriptions were given to patients with a CrCl > 30 to 60mL/min. 11/25 (44%) of these prescriptions were not adjusted for renal function. In all cases, the standard treatment dose was prescribed for those with normal CrCl. There were 3 prescriptions given to patients with a CrCl > 10 to 30 mL/min. All 3 prescriptions were appropriately adjusted for CrCl. Sulfamethoxazole-trimethoprim (800-160mg or 400-80mg) was dispensed 148 times. 13 prescriptions were given to patients with a CrCl 15-30ml/min. In 7/13 cases (54%), the dose was not adjusted for renal function. Only one prescription was inappropriately given to a patient with CrCl < 15 mL/min. Nitrofurantoin was prescribed 36 times; only on 1 occasion inappropriately to a patient with a CrCl < 30 mL/min.Conclusions: Medications that necessitate adjustment for renal impairment are commonly prescribed to geriatric patients upon discharge. In our subset analysis, nearly half the prescriptions dispensed to patients with a CrCl < 30mL/min were not appropriately adjusted for renal impairment. Ongoing ED physician education and further endeavors to improve medication safety i...
Background: Prison mental health services have tended to focus on improving the quality of care provided to mentally disordered offenders at the initial point of contact with the prison system and within the prison environment itself. When these individuals reach the end of their sentence and return to the community, there is an increased risk of morbidity, mortality, homelessness and re-imprisonment. New models of care have been developed to minimize these risks.Objectives: The objective of this project was to establish a Pre-Release Planning (PReP) Programme with social work expertise, to enhance interagency collaboration and improve continuity of care for mentally disordered offenders upon their release. We aimed to evaluate the first 2 years of the programme by measuring its success at improving the level of mental health support and the security and quality of accommodation achieved by participants upon release in comparison to that reported at time of imprisonment. Additionally, we aimed to explore the impact of these outcomes on rates of re-imprisonment.Methods: A process of participatory action research was used to develop and evaluate the first 2 years of the programme. This was a naturalistic prospective observational whole cohort study.Results: The PReP Programme supported 43 mentally disordered offenders, representing 13.7%, (43/313) of all new assessments by the prison's inreach mental health service during the 2 years study period. When compared with that reported at time of reception at the prison, gains were achieved in level of mental health support (FET p < 0.001) and security and quality of accommodation (FET p < 0.001) upon release. Of those participants seen by the PReP Programme, 20 (46.5%, 20/43) were returned to prison during the 2-years study period. There was no significant relationship between re-imprisonment and gains made in mental health support (FET p = 0.23) or accommodation (FET p = 0.23).Conclusions: We have shown that compared to that reported at time of reception at prison, the level of mental health support and the security of tenure and quality of accommodation both improved upon release following the intervention of the programme. Improved mental health support and accommodation were not associated with lower rates of re-imprisonment.
Objectives: Over 50% of inpatients with neurological disorders may present with a co-morbid psychiatric illness. Delirium has a reported point prevalence of 20% in hospital inpatients and is frequently undetected. We aimed to (1) examine inpatient referrals to a Liaison Neuropsychiatry service and (2) review the diagnosis and management of delirium before and after an educational intervention. Methods: An initial 6-month audit of referrals to the inpatient Liaison Neuropsychiatry service was conducted in 2018. We then undertook a psychoeducational intervention to raise awareness of the diagnosis and management of delirium. We conducted a re-audit of referrals to the service in 2019. Results: On initial audit, of 84 referrals, the most common referral was for mood (38%; n = 32). Just 4% (n = 3) had a specific delirium query. Following assessment by Neuropsychiatry, organic disorders (43%; n = 32), including delirium (33%; n = 25), were the most common diagnoses. On re-audit, of 86 referrals, mood assessment remained the most common reason for referral (38%; n = 33) and 2% (n = 2) were referred for possible delirium. Organic disorders remained the most common diagnoses (53%; n = 45) including delirium (38%; n = 32). We found a significant increase in the use of the delirium protocol from 12% (n = 3) on initial audit to 47% (n = 15); p < 0.01 on re-audit despite no increase in the number of specific delirium queries. Conclusions: A psychoeducational intervention improves the management of delirium by Neurologists and Neurosurgeons in patients with brain disorders.
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