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1.  Knowledge, attitude, and practices toward ayurvedic medicine use among allopathic resident doctors: A cross-sectional study at a tertiary care hospital in India 
Ayurveda is most commonly practiced form of complementary and alternative medicine (CAM) in India. There are very few studies showing the knowledge, attitude, and practices (KAP) of allopathic doctors about Ayurvedic drugs and its use.
The study was initiated to assess KAP toward Ayurvedic medicine use among allopathic resident doctors.
Settings and Design:
Cross-sectional and prospective study.
Materials and Methods:
After obtaining permission from the Institutional Ethics Committee, allopathic resident doctors from clinical departments were approached personally. They were given pre-formed validated questionnaire to assess KAP toward Ayurvedic medicine use.
Statistical Analysis Used:
Descriptive statistics.
Allopathic residents had little knowledge about basic concepts of Ayurveda, that is, ‘panchakarma’ and ‘tridosha’. Majority residents (99%) had no opportunity to learn basics of Ayurveda, but 67% residents prescribed Ayurvedic medicines to patients. However, many residents (76%) mentioned that cross practice should not be allowed due to lack of knowledge. One resident knew that cross-practice was not allowed by law. The commonly prescribed proprietary Ayurvedic medicines were Liv-52 (39%), Shatavari (13%), Cystone (12%) and common ailments for which these medicines prescribed were liver disorders (34%), arthritis (18%), cough and cold (13%), kidney stones (11%), and piles (10%). Nearly 76% residents felt incorporation of Ayurveda with modern medicine would attract more patients and at the same time most residents (92%) agreed that Ayurvedic medicines need scientific testing before use. Though 50% of the residents agreed for voluntary training in Ayurveda, 80% denied compulsory training. Nearly 63% residents recommended Ayurveda among all CAMs. Most of residents heard of Ayurveda from their colleagues.
This study reveals that allopathic resident doctors had little knowledge about Ayurveda and Ayurvedic medicine use but engaged in prescription of Ayurvedic medicines. So some interventions should be taken to increase the knowledge and awareness of allopathic resident doctors about Ayurvedic medicine use.
PMCID: PMC3757582  PMID: 24010059
Allopathy; Ayurveda; cross-practice; knowledge; attitude; and practices study; residents
2.  Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital 
The frequency of drug prescription errors is high. Excluding errors in decision making, the remaining are mainly due to order ambiguity, non standard nomenclature and writing illegibility. The aim of this study is to analyse, as a part of a continuous quality improvement program, the quality of prescriptions writing for antibiotics, in an Italian University Hospital as a risk factor for prescription errors.
The point prevalence survey, carried out in May 26–30 2008, involved 41 inpatient Units. Every parenteral or oral antibiotic prescription was analysed for legibility (generic or brand drug name, dose, frequency of administration) and completeness (generic or brand name, dose, frequency of administration, route of administration, date of prescription and signature of the prescriber). Eight doctors (residents in Hygiene and Preventive Medicine) and two pharmacists performed the survey by reviewing the clinical records of medical, surgical or intensive care section inpatients. The antibiotics drug category was chosen because its use is widespread in the setting considered.
Out of 756 inpatients included in the study, 408 antibiotic prescriptions were found in 298 patients (mean prescriptions per patient 1.4; SD ± 0.6). Overall 92.7% (38/41) of the Units had at least one patient with antibiotic prescription. Legibility was in compliance with 78.9% of generic or brand names, 69.4% of doses, 80.1% of frequency of administration, whereas completeness was fulfilled for 95.6% of generic or brand names, 76.7% of doses, 83.6% of frequency of administration, 87% of routes of administration, 43.9% of dates of prescription and 33.3% of physician's signature. Overall 23.9% of prescriptions were illegible and 29.9% of prescriptions were incomplete. Legibility and completeness are higher in unusual drugs prescriptions.
The Intensive Care Section performed best as far as quality of prescription writing was concerned when compared with the Medical and Surgical Sections.
Nevertheless the overall illegibility and incompleteness (above 20%) are unacceptably high. Values need to be improved by enhancing the safety culture and in particular the awareness of the professionals on the consequences that a bad prescription writing can produce.
PMCID: PMC2695418  PMID: 19439066
3.  PA01.51.Enriching the core 
Ancient Science of Life  2012;32(Suppl 1):S101.
Most of India population resides in rural and are not that economically sufficient to attend to rich healthcare bills of costly medicine, therapies and laboratory tests. The government is surely upto create more health centres and aid in future, as such this is a time taking project. On the other hand, an easy and effective way is following Ayurvedic life style and measures, moreover rural India is more closer to nature and the science of life, and it is more favourable to implement the ways mentioned in Ayurveda at core level. A study to verify the ways that can be advocated, from the basics of Ayurveda was projected.
Simple methods like following of dinacharya, ritucharya, sad vyavahar, plantation of home remedial medicinal plants along with the prime occupation of agriculture farming, using or organic fertilizer, following the medicinal ethics in rituals, protecting off from modern disorder causatives like sedentary lifestyle, junk canned foods, synthetic fertilizers, pollutants, etc. living in close with the nature, precisely Ayurvedic living seen to be very efficient.
The cost of healthcare expenses and maintainence was nullified, except the genetic and traumatic disorders most of them were very well handled or controlled before attaining full-blown condition. The concept of swasthavritta, nidaan parivarjan and samprapti vighatan could control most of the diseases. Health and happiness is a gift of life, was truly experienced. Implementing simple ways, which are in chorus with the lifestyle of rural, is not a complex issue. The results are highly benefitting and puts up a golden example for other to follow. It is in tune with enriching of public health through Ayurveda.
Rural population is the core of our country. Health to them in an economical and easy way Ayurveda will result a comprehensive progress to the whole country, and set an example for the world to follow.
PMCID: PMC3800854
4.  How to write a systematic review of reasons 
Journal of Medical Ethics  2011;38(2):121-126.
Systematic reviews, which were developed to improve policy-making and clinical decision-making, answer an empirical question based on a minimally biased appraisal of all the relevant empirical studies. A model is presented here for writing systematic reviews of argument-based literature: literature that uses arguments to address conceptual questions, such as whether abortion is morally permissible or whether research participants should be legally entitled to compensation for sustaining research-related injury. Such reviews aim to improve ethically relevant decisions in healthcare, research or policy. They are better tools than informal reviews or samples of literature with respect to the identification of the reasons relevant to a conceptual question, and they enable the setting of agendas for conceptual and empirical research necessary for sound policy-making. This model comprises prescriptions for writing the systematic review's review question and eligibility criteria, the identification of the relevant literature, the type of data to extract on reasons and publications, and the derivation and presentation of results. This paper explains how to adapt the model to the review question, literature reviewed and intended readers, who may be decision-makers or academics. Obstacles to the model's application are described and addressed, and limitations of the model are identified.
PMCID: PMC3262986  PMID: 22080465
Bioethics; decision making; ethics and evidence-based medicine (EBM); guideline development; health policy; information ethics; methods in empirical bioethics; review literature as topic; systematic review; technology/risk assessment
5.  Prescription writing practices in a rural tertiary care hospital in Western Maharashtra, India 
Prescription is a written order from physician to pharmacist which contains name of drug, its dose and its method of dispensing and advice over consuming it. The frequency of drug prescription errors is high. Prescribing error contributes significantly towards adverse drug events. The present study was undertaken to understand the current prescription writing practices and to detect the common errors in them at a tertiary health care centre situated in a rural area of Western Maharashtra, India.
A cross sectional study was conducted at a tertiary level hospital located at a rural area of Maharashtra state, India during October 2009-March 2010. 499 prescriptions coming to medical store during period of one month were considered for data analysis. Important information regarding the patient, doctor, drug and the general description of the prescription were obtained.
All the prescriptions were on the hospital pad. A significant number of the prescriptions (n=88, 17.6%) were written in illegible handwriting and not easily readable. The name, age and sex of the patient were mentioned is majority of the prescriptions. All the prescriptions (100%) failed to demonstrate the presence of address, height and weight of the patient. Only the brand name of the drugs was mentioned in all the prescriptions with none of them having the generic name. The strength, quantity and route of administration of the drug were found on 73.1%, 65.3% and 75.2% prescriptions.
There are widespread errors in prescription writing by the doctors. Educational intervention programs and use of computer can substantially contribute in the lowering of such errors. A short course on prescription writing before the medical student enters the clinical field and strict monitoring by the administrative authorities may also help alleviate the problem.
PMCID: PMC3562966  PMID: 23393497
Prescription; error; tertiary care hospital
Ancient Science of Life  1985;5(1):21-29.
Ayurveda, the ancient Indian “Science of Life” and age – old traditional medical science of India, has a recorded history of more than 2000 years. During this period certain changes and developments occurred in the conceptual framework of this science as well as in the political, socio – economic, and religion contexts in which Ayurvedic science must be seen. In his historical process one observes a continuous systematization, diversification, and specialization of the science.
Yet, among the central concerns of Ayurveda has always been promotion and maintenance of health and prevention of disease. Especially on the first topic one finds beautiful expositions in the early samhitas of Ayurvedic writing. But there is hardly any further elaboration on this subject in the later literature and until today. “It's all been said in Caraka”.
As the importance of health promotion and prevention medicine for comprehensive health care is now recognised, what is required today are not flat statements such as “Ayurveda is prevention in itself” but a critical assessment of the respective issues of Ayurvedic or any other old tradtion with a view to their relevance today, with a clear sigth of their limitations, and without loosing out of sight the ways and means required for their implementations.
PMCID: PMC3331437  PMID: 22557494
7.  Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India - a cross-sectional prescription analysis 
Diarrhoea accounts for 20% of all paediatric deaths in India. Despite WHO recommendations and IAP (Indian Academy of Paediatrics) and Government of India treatment guidelines, few children suffering from acute diarrhoea in India receive low osmolarity oral rehydration solution (ORS) and zinc from health care providers. The aim of this study was to analyse practitioners' prescriptions for acute diarrhoea for adherence to treatment guidelines and further to determine the factors affecting prescribing for diarrhoea in Ujjain, India.
This cross-sectional study was conducted in pharmacies and major hospitals of Ujjain, India. We included prescriptions from all practitioners, including those from modern medicine, Ayurveda, Homeopathy as well as informal health-care providers (IHPs). The data collection instrument was designed to include all the possible medications that are given for an episode of acute diarrhoea to children up to 12 years of age. Pharmacy assistants and resident medical officers transferred the information regarding the current diarrhoeal episode and the treatment given from the prescriptions and inpatient case sheets, respectively, to the data collection instrument.
Information was collected from 843 diarrhoea prescriptions. We found only 6 prescriptions having the recommended treatment that is ORS along with Zinc, with no additional probiotics, antibiotics, racecadotril or antiemetics (except Domperidone for vomiting). ORS alone was prescribed in 58% of the prescriptions; while ORS with zinc was prescribed in 22% of prescriptions, however these also contained other drugs not included in the guidelines. Antibiotics were prescribed in 71% of prescriptions. Broad-spectrum antibiotics were prescribed and often in illogical fixed-dose combinations. One such illogical combination, ofloxacin with ornidazole, was the most frequent oral antibiotic prescribed (22% of antibiotics prescribed). Practitioners from alternate system of medicine and IHPs are significantly less likely (OR 0.13, 95% CI 0.04-0.46, P = 0.003) to prescribe ORS and zinc than pediatricians. Practitioners from 'free' hospitals are more likely to prescribe ORS and zinc (OR 4.94, 95% CI 2.45-9.96, P < 0.001) and less likely to prescribe antibiotics (OR 0.01, 95% CI 0.01-0-04, P < 0.001) compared to practitioners from 'charitable' hospitals. Accompanying symptoms like the presence of fever, pain, blood in the stool and vomiting significantly increased antibiotic prescribing.
This study demonstrated low adherence to standard treatment guidelines for management of acute diarrhoea in children under 12 years in Ujjain, India. Key public health concerns were the low use of zinc and the high use of antibiotics, found in prescriptions from both specialist paediatricians as well as practitioners from alternate systems of medicine and informal health-care providers. To improve case management of acute diarrhoea, continuing professional development programme targeting the practitioners of all systems of medicine is necessary.
PMCID: PMC3045317  PMID: 21276243
8.  Editorial 
Interventional Neuroradiology  2001;6(4):269-276.
The 20 key points of the AP-HP document (Assistance Publique des Hopitaux de Paris)
1) Hospital doctors must provide health care recipients with information in compliance with standards laid down by the medical code of ethics.
2) Radiographers and nursing staff must contribute to the provision of information within the framework of their assigned responsibilities and in compliance with their professional rules.
3) Doctors must draft prescriptions clearly, ensure that the patient and immediate family circle understand them and encourage compliance.
4) Doctors have a duty when examining, treating or advising to provide clear, appropriate and fair information regarding the patienťs condition and the investigations and treatment proposed. During the course of the illness, physicians must take into account their patients' individual personalities when providing explanation and ensure these are understood.
5) Unless the condition places others at risk, a particularly grave diagnosis or prognosis may be withheld from a patient if the doctor, in good faith and for legitimate reasons, believes this to be in the best interests of the patient.
6) A patient should be informed of a fatal illness only after due consideration by the physician. Close relatives must always be informed, however, unless the patient has previously forbidden this or designated third parties to impart the information.
7) When several doctors collaborate on a diagnostic or treatment procedure, they must keep each other updated on the case. Each practitioner shall assume personal responsibility and inform the patient within the realm of his/her competence.
8) Oral information is priority and must be clear; fair, understandable and ordered.
9) The duty to inform is continuous. Consistent and constant information must be provided at all stages and, where possible, by the same physician.
10) Information must be provided on the benefits expected from a procedure and possible serious attendant risks; however exceptional.
11) Where possible, the practitioner should always verify that the information imparted has been properly understood.
12) It is recommended that:
- hospital doctors accompany oral information with printed leaflets where these aid understanding;
- departments set down a list of those invasive procedures requiring information leaflets. This practice will also help to standardise presentation of the risks and benefits.
13) Patients should not be requested to sign information sheets.
14) It is recommended that for each patient, one member of the medical team be designated, with responsibility for informing the patient and close relatives.
15) On patient admission, details of the family members to be informed must be systematically collected. Similarly, parents or guardians must be systematically contacted on the admission of children.
16) What information is to be given the patient and close family must be discussed by the medical group and the decisions taken recorded in the patient's file.
17) Each department shall define rules on giving information over the telephone to the family or immediate circle. These rules must be set down in writing and understood by all staff concerned.
18) Any information given to the patient must be noted in the medical file. It is to be presumed that only the details noted have been communicated. In this way, the patients' medical record serves as a communication tool for the various members of the medical team regarding the information given to the patient.
19) Obtaining written patient consent (permission to operate and similar documents) is neither compulsory nor recommended, except where required by law. The law demands that written consent be obtained for the following: biomedical research, fertility treatment, termination of pregnancy, genetic research, harvesting of organs from a living donor; certain organ harvesting from a deceased person, surgical procedures on a child.
20) In the event of litigation centring around failure to inform, no evidence, not even written evidence, is a watertight guarantee that the doctor has fulfilled his obligation. Whether information has been correctly imparted or not will be assessed on the basis of a range of elements such as: the period allowed the patient to take an informed decision, the number of visits, practitioners consulted before proceeding, the systematic provision of information leaflets and the notes made on the patient record.
PMCID: PMC3679700  PMID: 20667205
information to patients, consent, legal issues, radiology, interventional procedures, French hospitals
9.  Effects of Computer-based Prescribing on Pharmacist Work Patterns 
Abstract Objective: To measure the effect of computer-based outpatient prescription writing by internal medicine physicians on pharmacist work patterns.
Design: Work sampling at a hospital-based outpatient pharmacy. Data were collected from pharmacists wearing silent, random-signal generators before and after the implementation of computer-based prescribing.
Measurements: The type of work performed by pharmacists (activity), the reason for their work (function), and the people they contacted (contact) were measured.
Results: Total staff hours and prescriptions handled were similar before and after computer-based prescribing. Pharmacists recorded 4,687 observations before and 4,735 observations after implementation of computer-based outpatient prescription writing. After implementation, pharmacists spent 12.9 percent more time correcting prescription problems, had 3.9 percent less idle time, and spent 2.2 percent less time in discussions with others. Pharmacists also spent 34.0 percent less time filling prescriptions, 45.8 percent more time in problem-solving activities involving prescriptions, and 3.4 percent less time providing advice. Over 80 percent of pharmacist time was spent working alone both before and after computer-based outpatient prescription writing.
Conclusion: Computer-based prescribing results in major changes in the type of work done by hospital-based outpatient pharmacists and in the reason for their work and small changes in the people contacted during their work.
PMCID: PMC61334  PMID: 9824801
10.  Improving Electronic Oral Chemotherapy Prescription: Can We Build a Safer System? 
Journal of Oncology Practice  2012;8(6):e168-e173.
Oncology clinicians readily accepted features designed to enhance oral chemotherapy safety. Additional enhancements are needed to facilitate prescriptions with complex dosing regimens.
To prevent oral chemotherapy prescription errors, we enhanced a prescription-writing module in an ambulatory electronic medical record. We sought to describe the enhancement, examine its performance to date, and identify opportunities for improvement.
Enhancements to the oral chemotherapy writing module included weight- and body surface area–based dosing, fields for cancer diagnosis and intent of therapy (curative v palliative), and dose-limit warnings. We studied all prescriptions for 18 oral chemotherapies generated by oncology clinicians during the first 17 months after the safe prescribing enhancements were introduced, from May 1, 2010, to October 1, 2011. We examined the frequency with which clinicians used the new features, the number and type of alerts generated, and clinician actions in response to alerts.
Six hundred clinicians generated 6,673 prescriptions for 2,043 patients. Six drugs—temozolomide, capecitabine, lenalidomide, hydroxyurea, imatinib, and erlotinib—accounted for 5,512 of all oral chemotherapy prescriptions (83%). Prescribers indicated the intent of therapy 13% of the time and listed the patient's cancer diagnosis 46% of the time. Prescribers customized their instructions using a free-text field in 64% of prescriptions. Clinicians' 6,673 prescription attempts triggered 395 dose-limit warnings (5%), mostly for temozolomide. Clinicians ignored most (96%) warnings, because current dosing recommendations exceeded the dose-limit warnings for the alerted medications.
Oncology clinicians readily accepted features designed to enhance oral chemotherapy safety. Additional enhancements are needed to facilitate prescriptions with complex dosing regimens and to provide dose-limit warnings that reflect current clinical practice.
PMCID: PMC3500491  PMID: 23598852
11.  Ghost Authorship in Industry-Initiated Randomised Trials 
PLoS Medicine  2007;4(1):e19.
Ghost authorship, the failure to name, as an author, an individual who has made substantial contributions to an article, may result in lack of accountability. The prevalence and nature of ghost authorship in industry-initiated randomised trials is not known.
Methods and Findings
We conducted a cohort study comparing protocols and corresponding publications for industry-initiated trials approved by the Scientific-Ethical Committees for Copenhagen and Frederiksberg in 1994–1995. We defined ghost authorship as present if individuals who wrote the trial protocol, performed the statistical analyses, or wrote the manuscript, were not listed as authors of the publication, or as members of a study group or writing committee, or in an acknowledgment. We identified 44 industry-initiated trials. We did not find any trial protocol or publication that stated explicitly that the clinical study report or the manuscript was to be written or was written by the clinical investigators, and none of the protocols stated that clinical investigators were to be involved with data analysis. We found evidence of ghost authorship for 33 trials (75%; 95% confidence interval 60%–87%). The prevalence of ghost authorship was increased to 91% (40 of 44 articles; 95% confidence interval 78%–98%) when we included cases where a person qualifying for authorship was acknowledged rather than appearing as an author. In 31 trials, the ghost authors we identified were statisticians. It is likely that we have overlooked some ghost authors, as we had very limited information to identify the possible omission of other individuals who would have qualified as authors.
Ghost authorship in industry-initiated trials is very common. Its prevalence could be considerably reduced, and transparency improved, if existing guidelines were followed, and if protocols were publicly available.
Of 44 industry-initiated trials, there was evidence of ghost authorship in 33, increasing to 40 when a person qualifying for authorship was acknowledged rather than appearing as an author.
Editors' Summary
Original scientific findings are usually published in the form of a “paper”, whether it is actually distributed on paper, or circulated via the internet, as this one is. Papers are normally prepared by a group of researchers who did the research and are then listed at the top of the article. These authors therefore take responsibility for the integrity of the results and interpretation of them. However, many people are worried that sometimes the author list on the paper does not tell the true story of who was involved. In particular, for clinical research, case histories and previous research has suggested that “ghost authorship” is commonplace. Ghost authors are people who were involved in some way in the research study, or writing the paper, but who have been left off the final author list. This might happen because the study “looks” more credible if the true authors (for example, company employees or freelance medical writers) are not revealed. This practice might hide competing interests that readers should be aware of, and has therefore been condemned by academics, groups of editors, and some pharmaceutical companies.
Why Was This Study Done?
This group of researchers wanted to get an idea of how often ghost authorship happened in medical research done by companies. Previous studies looking into this used surveys, whereby the researchers would write to one author on each of a group of papers to ask whether anyone else had been involved in the work but who was not listed on the paper. These sorts of studies typically underestimate the rate of ghost authorship, because the main author might not want to admit what had been going on. However, the researchers here managed to get access to trial protocols (documents setting out the plans for future research studies), which gave them a way to investigate ghost authorship.
What Did the Researchers Do and Find?
In order to investigate the frequency and type of ghost authorship, these researchers identified every trial which was approved between 1994 and 1995 by the ethics committees of Copenhagen and Frederiksberg in Denmark. Then they winnowed this group down to include only the trials that were sponsored by industry (pharmaceutical companies and others), and only those trials that were finished and published. The protocols for each trial were obtained from the ethics committees and the researchers then matched up each protocol with its corresponding paper. Then, they compared names which appeared in the protocol against names appearing on the eventual paper, either on the author list or acknowledged elsewhere in the paper as being involved. The researchers ended up studying 44 trials. For 31 of these (75% of them) they found some evidence of ghost authorship, in that people were identified as having written the protocol or who had been involved in doing statistical analyses or writing the manuscript, but did not end up listed in the manuscript. If the definition of authorship was made narrower, and “ghost authorship” included people qualifying for authorship who were mentioned in the acknowledgements but not the author list, the researchers' estimate went up to 91%, that is 40 of the 44 trials. For most of the trials with missing authors, the ghost was a statistician (the person who analyzes the trial data).
What Do These Findings Mean?
In this study, the researchers found that ghost authorship was very common in papers published in medical journals (this study covered a broad range of peer-reviewed journals in many medical disciplines). The method used in this paper seems more reliable than using surveys to work out how often ghost authorship happens. The researchers aimed to define authorship using the policies set out by a group called the International Committee of Medical Journal Editors (ICMJE), and the findings here suggest that the ICMJE's standards for authorship are very often ignored. This means that people who read the published paper cannot always accurately judge or trust the information presented within it, and competing interests may be hidden. The researchers here suggest that protocols should be made publicly available so that everyone can see what trials are planned and who is involved in conducting them. The findings also suggest that journals should not only list the authors of each paper but describe what each author has done, so that the published information accurately reflects what has been carried out.
Additional Information.
Please access these Web sites via the online version of this summary at
Read the Perspective by Liz Wager, which discusses these findings in more depth
The International Committee of Medical Journal Editors (ICMJE) is a group of general medical journal editors who have produced general guidelines for biomedical manuscripts; their definition of authorship is also described
The Committee on Publication Ethics is a forum for editors of peer-reviewed journals to discuss issues related to the integrity of the scientific record; the Web site lists anonymized problems and the committee's advice, not just regarding authorship, but other types of problems as well
Good Publication Practice for Pharmaceutical Companies outlines common standards for publication of industry-sponsored medical research, and some pharmaceutical companies have agreed to these
PMCID: PMC1769411  PMID: 17227134
12.  Assessment vs. appraisal of ethical aspects of health technology assessment: can the distinction be upheld? 
An essential component of health technology assessment (HTA) is the assessment of ethical aspects. In some healthcare contexts, tasks are strictly relegated to different expert groups: the HTA-agencies are limited to assessment of the technology and other actors within the health care sector are responsible for appraisal and recommendations. Ethical aspects of health technologies are considered with reference to values or norms in such a way that may be prescriptive, or offer guidance as to how to act or relate to the issue in question. Given this internal prescriptivity, the distinction between assessment and appraisal seems difficult to uphold, unless the scrutiny stops short of a full ethical analysis of the technology. In the present article we analyse the distinction between assessment and appraisal, using as an example ethical aspects of implementation of GPS-bracelets for people with dementia.
It is concluded that for HTA-agencies with a strictly delineated assessment role, the question of how to deal with the internal prescriptivity of ethics may be confusing. A full ethical analysis might result in a definite conclusion as to whether the technology in question is ethically acceptable or not, thereby limiting choices for decision-makers, who are required to uphold certain ethical values and norms.
At the same time, depending on the exact nature of such a conclusion, different action strategies can be supported. A positive appraisal within HTA could result in a decision on mandatory implementation, or funding of the technology, thereby making it available to patients, or decisions to allow and even encourage the use of the technology (even if someone else will have to fund it). A neutral appraisal, giving no definite answer as to whether implementation is recommended or not, could result in a laissez-faire attitude towards the technology. A negative appraisal could result in a decision to discourage or even prohibit implementation. This paper presents an overview of the implications of different outcomes of the ethical analysis on appraisal of the technology. It is considered important to uphold the distinction between assessment and appraisal, primarily to avoid the influence of preconceived values and political interests on the assessment. Hence, as long as it is not based on the subjective value judgments of the HTA-agency (or its representative), such an appraising conclusion would not seem to conflict with the rationale for the separation of these tasks. Moreover, it should be noted that if HTA agencies abstain from including full ethical analyses because of the risk of issuing an appraisal, they may fail to provide the best possible basis for decision-makers. Hence, we argue that as long as the ethical analysis and its conclusions are presented transparently, disclosing how well-founded the conclusions are and/or whether there are alternative conclusions, the HTA-agencies should not avoid taking the ethical analysis as close as possible to a definite conclusion.
PMCID: PMC4260058  PMID: 25493102
assessment; appraisal; ethical analysis; prescriptiveness; surveillance technology; persons with dementia
13.  OA03.01. Biomedical studies on the classical ayurvedic treatment of rheumatoid arthritis in AVT, Coimbatore (19762011): After the biomedical auscultation, Ayurveda at a turning point? 
Ancient Science of Life  2013;32(Suppl 2):S24.
In India today Ayurveda lacks recognition and is underused. Modern research seems to be a key in Ayurveda's recognition. But it did not show much result. Why is it so? The relation between Ayurveda and biomedicine might impact the results of the biomedical research on Ayurveda. How would it happen?
Through a casestudy: Two biomedical studies on the classical ayurvedic treatment of rheumatoid arthritis at the Ayurvedic Trust (AVT), Coimbatore : WHOICMR (1976-1984) and NIHNCCAM (2005-10) allow a comparative approach with an historical perspective. An ethnographic approach (interviews ; participative observation ; literary research) to describe actors’ representations, capabilities, practices and relations within a specific context. With an anthropological approach (dependance), the two studies’ examination as development projects through project analysis tools (objectives, functions, means, roles, achievements). A comparative examination through parameters assessed for each study: a) Objectives’ achievement; b) Ayurveda's dependance on biomedicine according to the functions of the studies projects; and for each actor (Ayurveda vs biomedicine): c) Interest for the objectives; d) means and roles according to the functions.
A)Biomedical studies on Ayurveda do not aim at a better recognition of Ayurveda: our case study is an exception. B)Biomedical research on Ayurveda, its results and its impact are significantly dependent on biomedicine in its relation to Ayurveda. C)The historical perspective shows a development of Ayurveda's abilities in research: a) higher education of ayurvedic physicians and researchers; b) more experience of and expertise on research; c) better scientific communication tools and expertise.
The historical perspective indicates a movement towards Ayurveda's emancipation of biomedicine regarding research and the reformulation of its own agenda. Further research might include issues like the role of research in the recognition of Ayurveda and the overall relation between Ayurveda and biomedicine, specifically regarding the integrative approach. Social sciences might help.
PMCID: PMC4147493
14.  A study of the quality of prescriptions issued in a busy pediatric emergency room. 
Public Health Reports  1975;90(5):402-408.
An analysis of 2,213 prescriptions written by physicians in a busy, urban pediatric emergency room revealed that only 110 or 5 percent had no errors or omissions of specifications. The quality of the prescriptions was evaluated according to the standards of acceptable prescribing for the following specifications: quantity, dosage, time interval between doses or specific hours to be given, and specific instructions. The hospital pharmacists, also under pressure, generally failed to monitor the prescriptions adequately--either they did not rectify the physicians' errors or at times they made incorrect changes. To improve the quality of prescriptions issued under pressure in an emergency room, several courses of action are recommended: Pharmacology departments of medical schools should place more emphasis on teaching students the art of writing explicit, comprehensible prescriptions. The physician and pharmacist should work as a team in the interest of providing patients with accurate and detailed prescriptions; or both the physician and the pharmacist should delegate the composition of prescriptions to an automated computer system, thereby reducing human error in writing and monitoring prescriptions and allowing both professionals more time for direct contact with patients.
PMCID: PMC1437858  PMID: 809788
15.  Physical Therapists as Providers of Care: Exercise Prescriptions and Resultant Outcomes in Cardiac and Pulmonary Rehabilitation Programs in New York State 
Purpose: Physical therapists have engaged in cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) for decades, but the extent of their current involvement in this practice area is unclear. This study surveyed directors of CR and PR programs on a statewide level to ascertain what type of provider is writing the prescription, which methods of exercise formulation are used, which outcome measures are used and their congruency with established guidelines. Methods: A convenience sample of outpatient CR and PR directors (n=31) representing 38 CR and/or PR programs located in New York completed a survey in spring 2005 (29 CR and 9 PR). Results: Results showed that only 2 physical therapists were responsible for writing exercise prescriptions in CR and PR programs. Most program directors were registered nurses (53%), who also wrote the majority of CR exercise prescriptions. Exercise intensity was most frequently determined using formulae and data that were highly patient-specific. Clinical outcomes most frequently included Quality of Life scales and stress tests. Conclusions: Physical therapists are minimally involved in directing programs and writing exercise prescriptions. Exercise prescriptions are individualized to the patient. Outcome measures most frequently used by participating CR and PR program directors are consistent with nationally-recognized best practice.
PMCID: PMC2845219  PMID: 20467497
cardiopulmonary rehabilitation program(s); exercise prescription; outcomes; training
16.  Dyslexia: A solution through Ayurveda evidences from Ayurveda for the management of dyslexia in children: A review 
Ayu  2012;33(4):486-490.
Dyslexia is one of the commonest learning disability. It is defined as a disorder where a child, in spite of all the classroom teaching, is not able to attain the language skills of reading, writing and spelling according to their level of intelligence. Dyslexia individuals often have difficulty in relating to the association between sound and their respective letters. Reversing or transposing the letters while writing is characteristic with letters such as b and d, P and q, etc., The prevalence among school children is reported as 9.87% and in the selected families, it is 28.32%. Dyslexia significantly interferes with academic achievement or activities of daily life and are not primarily due to sensory, motor or mentally handicaps. About 40% of dyslexic children and adolescents dropout of schools. According to Ayurveda, learning is a result of successive and complex interaction of Indriyas (cognitive and motor organs), Indriyartha (sense organs), Mana (psyche), Atma and Buddhi (intellect). Above all, the functioning of these factors is governed by Tridosha (vata, pitta and kapha) and Triguna (Sattva, Raja and Tama) in a specific coordination and balance Any disturbance in these Tridosha and Triguna will cause disordered functioning of Indriya, Mana and Buddhi leading to impaired learning or Dyslexia Ayurvedic drugs can help in the management of dyslexia by making these Tridosha and Triguna in well-balanced state and also by providing Medhya (intellect promoting) drugs to improve the learning ability in these children.
PMCID: PMC3665203  PMID: 23723664
Ayurveda; dyslexia; Medhya; Tridosha; Triguna
17.  Hiring a professional medical writer: is it equivalent to ghostwriting? 
Biochemia Medica  2014;24(1):19-24.
Authors of articles published in medical journals are often busy researchers who cannot afford time devoted to writing. Though they are experts in their own therapeutic area, more often than not, researchers find it difficult to actually write and publish their research. Professional medical writers with their expertise in writing clear, concise, comprehensible, and coherent content are often a great support to researchers. Their contribution to the manuscript is usually focused on getting a manuscript ready for publication. They are not authors unless they make substantial contribution to the study according to the guidelines of the International Committee of Medical Journal Editors (ICMJE). However, medical writing is not the same as ghostwriting. Ghostwriting is unethical. Medical writers can be legitimate contributors to the medical manuscript. Several international guidelines including the ICMJE guidelines require authors to acknowledge the contribution of medical writers in the published article. Medical writers whose name is publicly associated with the article in turn make an extra effort to ensure that all applicable publication ethics and style guidelines are adhered to. This article discusses the current international guidelines about the acknowledgement of writing assistance. It also emphasizes on how acknowledging medical writing support can go a long way in curbing the menace of scientific misconduct including ghostwriting.
PMCID: PMC3936972  PMID: 24627711
medical writer; ghostwriter; authorship; ethics in publishing; acknowledgement
18.  A critique of statistical hypothesis testing in clinical research 
Many have documented the difficulty of using the current paradigm of Randomized Controlled Trials (RCTs) to test and validate the effectiveness of alternative medical systems such as Ayurveda. This paper critiques the applicability of RCTs for all clinical knowledge-seeking endeavors, of which Ayurveda research is a part. This is done by examining statistical hypothesis testing, the underlying foundation of RCTs, from a practical and philosophical perspective. In the philosophical critique, the two main worldviews of probability are that of the Bayesian and the frequentist. The frequentist worldview is a special case of the Bayesian worldview requiring the unrealistic assumptions of knowing nothing about the universe and believing that all observations are unrelated to each other. Many have claimed that the first belief is necessary for science, and this claim is debunked by comparing variations in learning with different prior beliefs. Moving beyond the Bayesian and frequentist worldviews, the notion of hypothesis testing itself is challenged on the grounds that a hypothesis is an unclear distinction, and assigning a probability on an unclear distinction is an exercise that does not lead to clarity of action. This critique is of the theory itself and not any particular application of statistical hypothesis testing. A decision-making frame is proposed as a way of both addressing this critique and transcending ideological debates on probability. An example of a Bayesian decision-making approach is shown as an alternative to statistical hypothesis testing, utilizing data from a past clinical trial that studied the effect of Aspirin on heart attacks in a sample population of doctors. As a big reason for the prevalence of RCTs in academia is legislation requiring it, the ethics of legislating the use of statistical methods for clinical research is also examined.
PMCID: PMC3193681  PMID: 22022152
Bayesian; decision analysis; statistical hypothesis testing
19.  “Science means learning to say—I don’t know”: An interview with Dr. Ashok D.B. Vaidya 
Dr. Ashok D.B. Vaidya, the stalwart in the fields of Experimental Pharmacology, Clinical Pharmacology, and Reverse Pharmacology turns 75 on Nov, 27, 2011. A former Clinical Research Head of CIBA Geigy Research Centre, his name has been synonymous with the concept of the Golden Triangle for resurgence of Ayurveda and its reinterpretation in modern scientific terms. At a time when most fields are populated by intellectual dwarfs and unethical operators, he stands like a giant–a scientist, a philosopher, and an ardent fighter for ethical values. In this free-wheeling interview with Ravindra R.Pandharinath, he discusses the milestones in his life, his inspirations, and dreams for the confluence of modern science, modern medicine, and Ayurveda as the new health care model for the 21st century
PMCID: PMC3255454  PMID: 22253513
Dr. Ashok Vaidya; golden triangle; reverse pharmacology
20.  PA01.61. Vrishya dravya- tool in shaping the corner stones of healthy society 
Ancient Science of Life  2012;32(Suppl 1):S111.
The principle aim of Ayurvedic aphrodisiac therapy Vrishya chikitsa is the birth of mentally and physically healthy children as they are the corner stones of a healthy future society. Modern life style is full of stress and competition thus interferes with physical mechanism of body creating psychosomatic impact leading to sexual inefficiency. Ayurvedic aphrodisiacs that enhance the vitality and give sexual power to couples, which enable them to give birth to healthy children. Western medicine relies on aggressive prescription of drugs and surgery to deal with many problems related to sexual dysfunction which in turn have unwanted and even dangerous side effects. In regards to this Scientists are searching for a safe and effective phytomedicine from Ayurveda.
Review of classical text and research data reported in various journals and monographs.
Vrishya chikitsa described in Ashtang Ayurveda mentions the reasons for sexual inefficiency and directs the use of several aphrodisiac herbs and minerals to enhance the vitality. Charaka has prescribed the use of aphrodisiacs that enhance the potency of a person. Ex. Ashwagandha, Mushali, Shatavari, Kapikacchu etc. Researches prove that, they enhance the reproductive capabilities and vigor of men while strengthening the body and overall well-being. In Ashwagandha main contain is withanolides, which are steroid lactones and have a quick and pronounced hormonal effect, which stimulate the development of testicular cells. Kapikacchu has been shown to increase sperm count. L dopa, a precursor of the neurotransmitter dopamine, isolated from Kapikacchu, has been shown to increase sperm production. The Vrishya chikitsa resorts to herb preparations and minerals, including nonpharmacological measures mentioned by Charaka like Sadvrutta palana and Aacharrasayana, also attain to enhance reproductive capabilities and vigor of men.
The herbs mentioned above and Sadavrutta, Achararasayana stands as an answer to solve problem of sexual inefficiency and enhance the potency of a person.
PMCID: PMC3800865
21.  OA03.17. Pilot retrospective observational study to evaluate efficacy of customized ayurvedic therapy on Type 2 diabetes exhibiting secondary failure of oral hypoglycemic drugs 
Ancient Science of Life  2013;32(Suppl 2):S40.
The data was retrospectively collected through third part unbiased documentation conducted under RUDRA program at The Arya Vaidhya Chikitsalayam and Research Institute. Obtained data was evaluated to study the efficacy of customized ayurvedic therapy in on Type 2 diabetes exhibiting secondary failure of oral hypoglycemic drugs.
Participants were retrospectively selected between Jan. to Dec. 2011 diagnosed with Type 2 Diabetes mellitus as primary or secondary morbidity during documentation. Out of 194 patients who visited our OPD with primary aim as management of their type 2 diabetes 27 cases found to have adequate baseline and endpoint data and satisfying the inclusion criterion were delineated, exhibiting secondary failure to oral hypoglycemic drug. At least 1 prescription claim for a sulfonylurea or a thiazolidinedione during study period along with metformin use include in the study. Secondary failure was measured for patients who initially achieved a Fasting and Post prandial blood glucose 126 mg/dl and 200 mg/dl but in due course of chronicity again rose above the said level, exhibiting secondary failure of oral hypoglycemic drugs
Participants (mean age, 50.034 (S.D. ±13.64) years; 55.6% female and 44.4 % males) who were known diabetic since 5.9185 (S.D. ±6.6) underwent a customized Ayurveda treatment with Allopathic oral hypoglycemic drugs as concomitant medication for average of 16.2 weeks. The mean baseline Fasting and Post prandial blood glucose was 163.26 (S.D. ± 50.57) and 230.23 (S.D.± 90.24244) and which was higher for the patients receiving a combination of metformin and sulfonylurea or thiazolidinedione. The mean Fasting blood glucose decreased to 131.49, and Post prandial 174.5 of patients as compared to baseline. This reduction in the Gycemic index was found to be statistically significant after administration of unpaired students ‘t’ test at significance level of <0.05.
Customized Ayurveda treatment was able to ameliorate the Fasting and Post prandial blood sugar levels in patients with secondary failure to oral hypoglycemic drugs with type 2 diabetes.
PMCID: PMC4147511
22.  Redesigning the ‘choice architecture’ of hospital prescription charts: a mixed methods study incorporating in situ simulation testing 
BMJ Open  2014;4(12):e005473.
To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors.
A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart.
A London teaching hospital.
A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation.
Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart.
In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.
PMCID: PMC4256638  PMID: 25475242
EDUCATION & TRAINING (see Medical Education & Training)
23.  Systematic and transparent inclusion of ethical issues and recommendations in clinical practice guidelines: a six-step approach 
Clinical practice guidelines (CPGs), a core tool to foster medical professionalism, differ widely in whether and how they address disease-specific ethical issues (DSEIs), and current manuals for CPG development are silent on this issue. The implementation of an explicit method faces two core challenges: first, it adds further complexity to CPG development and requires human and financial resources. Second, in contrast to the in-depth treatment of ethical issues that is standard in bioethics, the inclusion of DSEIs in CPGs need to be more pragmatic, reductive, and simplistic, but without rendering the resulting recommendations useless or insufficiently justified. This paper outlines a six-step approach, EthicsGuide, for the systematic and transparent inclusion of ethical issues and recommendations in CPGs.
The development of EthicsGuide is based on (a) methodological standards in evidence-based CPG development, (b) principles of bioethics, (c) research findings on how DSEIs are currently addressed in CPGs, and (d) findings from two proof-of-concept analyses of the EthicsGuide approach.
The six steps are 1) determine the DSEI spectrum and the need for ethical recommendations; 2) develop statements on which to base ethical recommendations; 3) categorize, classify, condense, and paraphrase the statements; 4) write recommendations in a standard form; 5) validate and justify recommendations, making any necessary modifications; and 6) address consent. All six steps necessarily come into play when including DSEIs in CPGs.
If DSEIs are not explicitly addressed, they are unavoidably dealt with implicitly. We believe that as ethicists gain greater involvement in decision-making about health, personal rights, or economic issues, they should make their methods transparent and replicable by other researchers; and as ethical issues become more widely reflected in CPGs, CPG developers have to learn how to address them in a methodologically adequate way. The approach proposed should serve as a basis for further discussion on how to reach these goals. It breaks open the black box of what ethicists implicitly do when they develop recommendations. Further, interdisciplinary discussion and pilot tests are needed to explore the minimal requirements that guarantee a simplified procedure which is still acceptable and does not become mere window dressing.
PMCID: PMC4265426  PMID: 25472446
Clinical practice guideline; Guideline development; Ethical recommendation; Clinical ethics; Medical professionalism
24.  Exploring issues in the development of Ayurvedic research methodology 
Research is the prime need of contemporary Ayurveda, but modern research on Ayurveda has not been very rewarding for Ayurveda itself. Much of it uses Ayurveda to extend modern bioscience. In contrast, Ayurveda needs research designed to test and validate its fundamental concepts as well as its treatments. In this context, if Ayurveda is to be truly explored and validated in all its aspects, scientific inputs should conform to Ayurveda's principles and philosophy. While its evidence base, established since antiquity, may need further verification, research should now focus on the Science of Ayurveda, rather than merely looking for new drugs based on Ayurveda herbals; in-depth research is needed on Ayurveda. Such research will require teamwork between scientists and vaidyas based on truth and trust. Ayurveda research methodology requires the ‘whole system testing approach’, global participation with protocols evolved through intense interface with modern science, regulatory reforms to eliminate barriers, and to be investigated ‘as it is’, using approaches adapted from its own basic principles.
PMCID: PMC3151394  PMID: 21836794
Ayurveda; research; methodology
25.  A principled and cosmopolitan neuroethics: considerations for international relevance 
Neuroethics applies cognitive neuroscience for prescribing alterations to conceptions of self and society, and for prescriptively judging the ethical applications of neurotechnologies. Plentiful normative premises are available to ground such prescriptivity, however prescriptive neuroethics may remain fragmented by social conventions, cultural ideologies, and ethical theories. Herein we offer that an objectively principled neuroethics for international relevance requires a new meta-ethics: understanding how morality works, and how humans manage and improve morality, as objectively based on the brain and social sciences. This new meta-ethics will simultaneously equip neuroethics for evaluating and revising older cultural ideologies and ethical theories, and direct neuroethics towards scientifically valid views of encultured humans intelligently managing moralities. Bypassing absolutism, cultural essentialisms, and unrealistic ethical philosophies, neuroethics arrives at a small set of principles about proper human flourishing that are more culturally inclusive and cosmopolitan in spirit. This cosmopolitanism in turn suggests augmentations to traditional medical ethics in the form of four principled guidelines for international consideration: empowerment, non-obsolescence, self-creativity, and citizenship.
PMCID: PMC3892081  PMID: 24387102
Neuroscience; Prescriptive neuroethics; Principled neuroethics; Cultural pluralism; Meta-ethics; Cosmopolitanism; Medical ethics

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