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---------------------------------------------------------------------------------
-----------------------

E-Drug Digest             Friday, 13 December 1996      Volume 96 : Number 001

In this issue:

        E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training
        E-DRUG: Abortion drugs
        E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Tr
        E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training
        E-DRUG: Asthenia as indication & side-effects of L-carnitine
        E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training

See the end of the digest for information on how to retrieve back issues.

----------------------------------------------------------------------

From: Rodolfo Dennis - Director Unidad de Epidemiologia Clinica
<rdennis@javercol.javeriana.edu.co>
Date: Fri, 13 Dec 1996 03:12:46 -0500
Subject: E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training

Dear E-drugers,

The issue with the impact of undergratuate prescribing courses on 
rational prescribing may be in part one of learning good  
practices that are finite in time, instead of promoting a more profound
change in medical curriculums and continuing education programs towards the 
development of evidence-based medical practice - learning the principles 
of critical appraisal of the available evidence rather than what is 
rational or irrational at a specific point in time, which is only quite 
likely to be time-dependent. Viewed this way, the issue of when to teach 
good prescribing is one of too little, too late if near or around 
internship & residence when students are quite busy and coping, or too 
early, too much when students are learning pharmacology.   

Is there evidence that graduates of schools of med with strong curriculums based
on the practice of evidence-based medicine "fare
better" in prescribing practice, whatever it means? 


Rodolfo Dennis
Universidad Javeriana
Bogota, Colombia
email: rdennis@javercol.javeriana.edu.co
 

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------------------------------

From: "Marita van Rooyen" <VROOYM@hltrsa.pwv.gov.za>
Date: Fri, 13 Dec 1996 08:17:58 -0500
Subject: E-DRUG: Abortion drugs

Dear E-druggers,

We need information on the use of drugs to induce abortions - 
misoprostol, mifepristone and methotrexate. We have info from medline 
and would like to know more about the actual use and problems.

Send info to matsop@hltrsa.pwv.gov.za

Marita van Rooyen
Department of Health
South Africa  

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------------------------------

From: LIDDELL <Merilyn.Liddell@med.monash.edu.au>
Date: Fri, 13 Dec 1996 08:18:33 -0500
Subject: E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Tr

Richard,

I think that the concept you raise of sensitising people to the 
issues in prescribing, rather than changing prescribing practices in 
a measurable way from a single intervention is going to prove to be 
the crux of the matter.

Anecdotally, I came to have an interest in the area of Rational Prescribing 
rather by accident, and from a career in ordinary general practice. I 
found that even though I was reading and writing about the principles 
of good prescribing, I would still find myself reverting to old 
habits at times under the pressures which exist in general practice 
(lack of time, patient expectations, habits, etc) Over time, and 
because I was becoming sensitised to the issues, I think my real 
prescribing has improved - certainly I think about it more. 

So I think we need to be looking at long term means of changing 
prescribing cultures, and not expect single courses or interventions, 
no matter how sound, to achieve and maintain significant change. (I 
would also like to be proved wrong on this.)

Regards

Merilyn
Dr Merilyn Liddell
Senior Lecturer
Department of Community Medicine
Monash University
Australia
email Merilyn.Liddell@med.monash.edu.au 

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------------------------------

From: Proyecto SSD <mshnic@ibw.com.ni>
Date: Fri, 13 Dec 1996 08:21:28 -0500
Subject: E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training

Dear E-druggers,

Lack of impact from training is an issue that the Decentralized Health
Services Project (Proyecto de Servicios Decentralizados -- PSSD) in
Nicaragua has begun to address.

We developed a training methodology which has been used for rational
antibiotic prescription with ARI's.  This training methodology begins with
the participants' active assessment of their own treatment and diagnosis
parterns through review of their own case files and daily registers.  This
information is compared with the treatment algorithms developed by WHO and
PAHO.  Goals are made regarding correct treatment.  Participants later meet
to report on their progress and a systematic review of treatment is
conducted.  A key component of this training is physicians' on-going self
audit which facilitates a new attitute in the application of correct norms.
Antibiotic use has been demonstrated to decline.  This, in turn, increase
availability.

In various training sessions conducted we found that although adequate and
thorough training had been provided, it did result in a change in treatment
patterns.  A crucial component was a simple and easy way to allow physicians
to monitor their own patterns and that on-going monitoring and evaluation at
the individual and facility level is institutionalized.  
- --------------------------------------------------------------------------
Catherine Dormitzer
Mary Luz Dussan 
Management Sciences for Health
Projecto de Servicios de Salud Descentralizados (PSSD)
MINSA - Complejo "Dra Concepcion Palacios"
Apartado 4636 - Managua, Nicaragua
Telf:   505- 289-4801  505-289-0401
FAX:    505-289-0369
e-mail: mshnic@ibw.com.ni 

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------------------------------

From: jeromjet@easynet.fr (Jerome Sclafer)
Date: Fri, 13 Dec 1996 08:21:25 -0500
Subject: E-DRUG: Asthenia as indication & side-effects of L-carnitine

Dear e-druggers,

Recently, L-carnitine has been marketed in France with the official
indication of "functional asthenia". Of course, this indication has no real
meaning. 
Since 16 years in la revue Prescrire, has been presented a critical review
of all dugs marketed in France. For this case of L-carnitine, in order to
give some more weight to our article, we are trying to find out whether or
not L-carnitine has already been marketed, as registered drug, for any
approaching indication in any other country. Please do not mention products
which would have been registered as nutritive substances and not as drug.
So far the review of litterature shows that not one single published study
has tried L-carnitine for asthenia, although it desesperately tried it for
too many other indications. Our conclusion is that this marketing is
equivalent to marketing a placebo. This is why we also concentrate our
research on side effects, including interactions. We've already explored
Meyler's side effects of drugs, Meyler's annual and Reactions databases. If
you are aware of any report, especially in country where L-carnitine is much
used like Italy, could you please send the reference or if possible a copy.

Thanks in advance,

** Jerome Sclafer                                       **
** La revue Precrire - Member of the Editorial Team     **
** E-mail: jeromejet@easynet.fr                         **
** Prescrire tel: +33 1 4700 9445  fax: +33 1 4807 8732 **

P.S. By the way, la revue Prescrire does exist in English: Precrire
International. If interested ask for information.
 

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------------------------------

From: "Emilio J. Sanz" <esanz@ull.es>
Date: Fri, 13 Dec 1996 08:21:40 -0500
Subject: E-DRUG: Re: Lack of Impact from Undergraduate Prescibing Training

Dear colleagues,

I do agree with Richard Laing in the opinion that undergraduate training has
(possibly) low impact in precribing behaviour later on, under the "real"
working conditions. In fact, most practitioners do learn therapeutics from
the 2nd year residents.... or other young peers. But the whole question
is about what do really mean by "rational prescribing", "Rational use of
drugs" or even "Good Prescribing Practices". The inter-country differences
in drug prescribing, as observed through multiple Drug Utilization Studies,
show such a big differences in the therapeutic traditions from one country
to another, or even in regions withina country, that the "international
consensus" something are just a kind of "gold standard" at, approximately,
the same distance as ... heaven!. There are more cultural, social -anthropo-
logical- factors influencing drug prescribing that changes in morbidity or
mortality. May be the training of pre-graduate (and post-graduate) students
should be directed to teach the skills for a critical evaluation of the new
medication, and to "implement" on them the idea of a continuous revision of 
their therapeutic habits.

In this sense the work by the WHOPER and Theo de Vries is more directed 
toward teaching the idea of self-selection, and self re-evaluation. We
ask our students on the last year of Medicine to prepare their own
"personal Formulary" with no more than 50 pharmaceutical specialities
(out of the 10.000 in the Spanish market). As this is evaluated for the
final score, the main topic for the students are not the actual therapeutic
regimens, or the appropriate treatment of certain conditions, but rather,
the criteria used for the selection of that particular presentation.

They will probably not follow that "Personal Formulary" more than few months,
but we hope to be able to teach them how to revise it every now and then.
It is hard to show any objective improvement, but the main question I would
put into the discussion is about the variables to be meassured to elicit
such improvement....

It is a hot and difficult topic, but very relevant for those dealing with
academical work.

Emilio J. Sanz, MD, PhD
Senior Lecturer in Clinical Pharmacology
Universidad de La Laguna
38071 La Laguna. Tenerife 
Spain
Tfno:+34 (9)22 603477, -71
Fax :+34 (9)22 655995 

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------------------------------

End of E-Drug Digest V96 #1
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