Objective To describe the findings of the first cycle of a clinical audit of antimicrobial use by general dental practitioners (GDPs).Setting General dental practices in Wales, UK.Subjects and methods Between April 2012 and March 2015, 279 GDPs completed the audit. Anonymous information about patients prescribed antimicrobials was recorded. Clinical information about the presentation and management of patients was compared to clinical guidelines published by the Scottish Dental Clinical Effectiveness Programme (SDCEP).Results During the data collection period, 5,782 antimicrobials were prescribed in clinical encounters with 5,460 patients. Of these 95.3% were antibiotic preparations, 2.7% were antifungal agents, and 0.6% were antivirals. Of all patients prescribed antibiotics, only 37.2% had signs of spreading infection or systemic involvement recorded, and 31.2% received no dental treatment. In total, 79.2% of antibiotic, 69.4% of antifungal, and 57.6% of antiviral preparations met audit standards for dose, frequency, and duration. GDPs identified that failure of previous local measures, patient unwillingness or inability to receive treatment, patient demand, time pressures, and patients' medical history may influence their prescribing behaviours.Conclusions The findings of the audit indicate a need for interventions to support GDPs so that they may make sustainable improvements to their antimicrobial prescribing practices.
Principals and trainees in general practice attending training events were asked to give information about their prescribing of drugs, with a focus on the prescribing of benzodiazepines for psychological problems. High prescribers of benzodiazepines believed that a prescription saved consultation time, tended to be influenced by drug company information and believed that patients expected a prescription. Low prescribers of benzodiazepines did not prescribe for bereavement, wished to have more psychological expertise and offered treatments other than drugs. Doctors classified as empathic from their statements at interview found difficulty in ending consultations and thought that social problems should be part of the general practitioner's work, although there were no differences between empathic and unsympathetic doctors in overall prescribing rates of benzodiazepines. The data suggest that doctors who are emphatic towards their patients would prescribe less if they had training in psychological skills.
Background: The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract. Aim: This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract. Method: Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis. Findings: The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients' openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the individual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient's attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer. Conclusion: A CAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions.
Introduction A range of techniques have been described to achieve successful cannulation at ERCP, and when training in ERCP it is often difficult to select the optimum approach .1 There are potential advantages to a wire-led approach and we have evaluated this in our unit in a training setting. Aim To evaluate cannulation success rates for trainers and trainees using a wire-led technique as the default approach. Methods A prospective evaluation was done with 2 experienced trainers and 2 trainees (previous experience of 50-100 ERCPs each). The sphincterotome was pre-loaded with a hydrophilic wire (in limited cases loop tip wire was used) and cannulation started with the wire extending 3-5 mm out of cannula. Attempts were then made to advance the wire deep into the bile duct before injecting any contrast or pushing the cannula through the ampulla. Trainees were allowed 6 min for cannulation attempts. If the wire-led approach failed then other techniques were used. Wire-led cannulation was considered successful only if no other techniques were required. Only cases with a 'virgin ampulla' were including in this study. Results 85 cases were included over a 4 month period. Trainees were present in 51/85 (60%) cases. Overall biliary cannulation success was 78/85 (92%). Success rate was 45/51 (88%) if a trainee was present and 33/34 (97%), if no trainee was present. Independent success for trainees was 25/51 (49%), mostly using the wire-led technique (21/25) 84%. In cases where a trainer took over from a trainee, the wire-led approach was still successful in 13/26 (50%). Overall success with the wire-led approach alone was 57/85 (67%); other approaches used in remaining cases included precut sphincterotomy, locked PD wire, and PD stent. A periampullary diverticulum was the most common cause for failure of wire-led technique; other common causes included stricture, floppy ampulla, or an impacted stone. Median cannulation time was 6.5 min (IQR 4-10 min) overall and 5 min (IQR 3-10 min) for consultant-only cases. Immediate complications included false passage of wire (1 case, no further clinical events) and late complications: post ERCP pancreatitis (1 case, hospital stay 3 days, no further clinical events). Conclusion Wire-led biliary cannulation, with selective usage of additional techniques, may allow a cannulation rate of >90% in cases with a virgin ampulla. The technique appears to be a useful training tool and has a low complication rate. REFERENCE
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