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Twenty-twenty was challenging for everyone, particularly for the health professionals at the front line of New Zealand's response to the COVID-19 pandemic. While New Zealand has experienced low COVID-19 case and mortality rates and few ongoing restrictions compared to many other countries, the effects of the pandemic continue to be felt, e.g. the August, 2021 Delta variant outbreak and return to Level 4 restrictions. The key events in New Zealand's COVID-19 pandemic 2020 timeline are outlined in Figure 1. The four-week national Level 4 "lockdown" and the following three weeks of further restrictions from 25 March until 13 May saw most people staying at home, with many adapting to working and learning remotely. Another cluster of cases in August moved Auckland up to Alert Level 3 (effectively another lockdown) for two weeks.

Figure 1: Overview of key events in the COVID-19 pandemic in New Zealand in 2020. ¹

Primary care rapidly adapted to the COVID-19 pandemic, particularly with respect to the use of technology to enable patients to access care remotely. Examining the dispensing data provides an opportunity to reflect on 2020 and whether there were any notable trends as a result of the changes to and challenges of general practice during this time. This report raises and addresses the following questions about dispensing in the community in 2020:

Were there changes in the number of dispensed prescriptions overall and was there any evidence of worsening inequities in dispensing by ethnicity?

Were there changes in antibiotic dispensing given the lower rates of respiratory illness due to various measures, including lockdowns, social distancing, wearing face masks, hygiene measures and high rates of influenza vaccination?

Were there changes in the dispensing of antidepressants, anti-anxiety or insomnia medicines given the potential for stress associated with the pandemic to trigger or worsen depression, anxiety or sleep issues?

Were there changes in the dispensing of medicines used for the management of long-term conditions commonly encountered in primary care, i.e. did people remain adherent despite the restrictions of the lockdowns?

Overall, approximately 236,000 more prescriptions were dispensed in 2020 than 2019 (an increase of 0.5%). However, after adjusting for population, the number of dispensed prescriptions (per 1,000 registered patients) was 1% lower in 2020 than 2019 ( Figure 2). The number of dispensed prescriptions has remained relatively stable over time, increasing by 2% between 2018 and 2019, no change between 2017 and 2018, and decreasing by 1% between 2016 and 2017. The decrease in dispensing in 2020 suggests there may have been some patients who did not receive medicines they would have otherwise received, e.g. due to not obtaining a repeat prescription, not presenting to primary care (virtually or in person) for diagnosis and management, or reduced need for certain medicines (see: " Antibiotic dispensing ").

Figure 2: Total number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand, 2016 - 2020.

Figure 3 shows the number of dispensed prescriptions (per 1,000 registered patients) by month between 2016 and 2020. Dispensing in March, 2020 was markedly higher than the same month in the previous four years. There were 1,008,418 more prescriptions (200 per 1,000 registered patients) dispensed from community pharmacies in March, 2020 compared to March, 2019, reflecting the trend of people "stocking up" on prescriptions prior to the national lockdown. This was followed by a comparable decrease in dispensing in April, 2020 - there were 750,890 fewer dispensed prescriptions (168 per 1,000 registered patients) than in April, 2019. Following the March peak and April trough in 2020, the dispensing rate increased steadily and by August was comparable to 2019. There was another peak in dispensing in November, 2020, which was higher than previous years. Anecdotally, there have been reports that some patients stopped taking their regular preventative medicines during the national lockdown and did not resume them until later in the year, which may explain this observation.

Figure 3: Number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand by month, 2016 - 2020. The dotted line represents the linear trend in dispensing over time.

Total community dispensings in New Zealand by ethnicity, 2016 - 2020

The COVID-19 pandemic has disproportionately burdened communities who were already experiencing inequities in healthcare. In New Zealand, ethnic minorities have poorer health outcomes compared to those of European descent, which includes access to medicines. The peak in dispensing prior to the national lockdown ( Figure 3) shows that many people rapidly accessed healthcare, but this required further examination to see if this effect was seen in all ethnic groups or if differences in the ability to access healthcare in this way (e.g. due to cost, transport, time away from work or childcare, internet access for virtual appointments) affected access to medicines.

Figure 4 shows the number of dispensed prescriptions (per 1,000 registered patients) by ethnicity between 2016 and 2020. During this time period, the dispensing rate was relatively stable for all ethnic groups; the largest change was for Pacific peoples between 2018 and 2019 (3% increase). Between 2019 and 2020, however, the dispensing rate decreased for all ethnic groups except European/Others ( Table 1). This was in contrast to an increase of 2 - 3% for all ethnic groups between 2018 and 2019.

Figure 4: Total number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand by ethnicity, 2016 - 2020.

Table 1: Percentage change in the number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand by ethnicity between 2018 - 2019 and 2019 - 2020.

Ethnic group Change 2018/2019 Change 2019/2020

European/Other
2% increase

0%

Figure 5 shows the dispensing rate by ethnicity by month in 2020. There was a similar peak and trough in March and April, respectively, in 2020 for each ethnic group, corresponding to the national lockdown. Dispensing after the national lockdown did not recover to the same extent in Māori, Pacific and Asian peoples as for European/Others, which is reflected in the overall lower dispensing rate in 2020 than 2019 for these ethnic groups ( Figure 4). Together these data suggest that the effects of the COVID-19 pandemic in 2020 may have increased disparities and adherence issues with people not resuming preventative medicines, but may also reflect reduced need for some medicines at this time, e.g. antibiotics (see: " Antibiotic dispensing ").

Figure 5: Number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand by ethnicity, by month in 2020.

Overall, antibiotic dispensing has been trending downward over time due to improved antimicrobial stewardship. Dispensing of oral antibiotics dropped dramatically in 2020, with 20% fewer prescriptions dispensed (per 1,000 registered patients) in 2020 than 2019, compared to a 3% decrease in the number of dispensed prescriptions between 2019 and 2018. The 2020 pandemic response saw the adoption of various practices to mitigate transmission of COVID-19, including lockdowns, social distancing, wearing face masks, hygiene measures and high rates of influenza vaccination. This resulted in not only low numbers of COVID-19 cases, but also a reduction in other infectious illnesses, e.g. upper respiratory tract infections and influenza. Improved public awareness of viral infections and acceptance of the limited role of antibiotics in treatment also likely contributed to the marked reduction in antibiotic dispensing in 2020.

Antibiotic dispensing rates typically increase over the winter months, reflecting more people presenting to primary care with respiratory tract infections and receiving a prescription for antibiotics. Figure 6 shows that there was a marked decrease in dispensing in the second quarter of 2020 (April - June) and the absence of a peak in the third quarter (July - September) compared to the same periods in 2019. Antibiotic dispensing rates are usually highest in Pacific peoples and Māori, followed by Europeans/Other and lowest in Asian peoples ( Figure 7). There was a marked decrease in antibiotic dispensing in all ethnic groups in 2020, with the largest decreases in Asian and Pacific peoples ( Table 2).

Figure 6: Number of dispensed prescriptions (per 1,000 registered patients) for oral antibiotics from community pharmacies in New Zealand by quarter, 2019 and 2020.

Table 2: Percentage change in the number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand by ethnicity between 2018 - 2019 and 2019 - 2020.

Figure 7: Number of dispensed prescriptions (per 1,000 registered patients) for oral antibiotics from community pharmacies in New Zealand by ethnicity, 2016 - 2020.

The COVID-19 pandemic was, and continues to be, stressful for many people for a variety of reasons, including health concerns, job loss or insecurity, isolation from family/whānau and friends, and balancing working-from-home with childcare, schooling and family relationships. These factors would be expected to increase presentations to primary care of people with symptoms of distress, depression, anxiety and sleep problems, and potentially result in more prescriptions for antidepressants, anxiolytics and hypnotics in 2020 compared to previous years. The data show that, in general, this was not the case, although there may have been more antidepressants dispensed.

Antidepressants

Figure 8 shows that the number of dispensed prescriptions for selective serotonin re-uptake inhibitors (SSRIs) has been steadily increasing over time; dispensing of tricyclics and other antidepressants has remained relatively stable between 2016 and 2020. There was a 7% increase in SSRI dispensing between 2019 and 2020, compared to 4% between 2018 and 2019 and 1% increases between both 2016 and 2017 and 2017 and 2018. While the expected rate of change over time is not known, the 7% increase in dispensing rate in 2020 appears larger than the usual rate of increase.

Figure 8: Number of dispensed prescriptions (per 1,000 registered patients) for antidepressants from community pharmacies in New Zealand by quarter, 2016 - 2020. Dotted lines represent the linear trend in dispensing over time.

Profile of patients newly initiated or re-initiated on an antidepressant, 2018 - 2020

In 2020, a total of 543,842 patients (114 per 1,000 registered patients) were dispensed an antidepressant. Of these, 28% were newly initiated or re-initiated, i.e. were not dispensed an antidepressant in the previous year ( Table 3). Unexpectedly, the COVID-19 pandemic did not seem to have a marked effect on the number of patients initiated on an antidepressant, as the proportion of new patients was comparable to previous years ( Table 3).

In those initiated on antidepressants in 2020, the dispensing rate (number of patients per 1,000 registered patients) was highest in those aged 20 - 39 years and over age 80 years, which was consistent with 2018 and 2019.

Table 3: Characteristics of patients (per 1,000 registered patients) initiated on antidepressants, 2018 - 2020.

* No antidepressant dispensed in the previous year

Zopiclone, benzodiazepines and quetiapine

The number of dispensed prescriptions for zopiclone, indicated for the treatment of insomnia, has remained relatively stable over the past five years and there was no marked change in this trend in 2020 ( Figure 9). Conversely, the number of dispensed prescriptions for benzodiazepines, which are indicated for the management of anxiety and insomnia, has been trending upward since 2017 ( Figure 9). There was a 2% increase in the number of dispensed prescriptions for benzodiazepines between 2019 and 2020, compared to previous increases of 1% between 2018/2019 and 2017/2018 and a 2% decrease between 2016 and 2017, i.e. much the same.

Quetiapine is an atypical antipsychotic indicated for the treatment of psychosis and bipolar disorder; it is also used off-label for the treatment of insomnia, anxiety, post-traumatic stress disorder and the behavioural and psychological symptoms of dementia (BPSD). Figure 9 shows an upward trend in quetiapine dispensing since 2016. Between 2019 and 2020, the number of dispensed prescriptions for quetiapine increased by 10%, continuing the pattern of increase seen in previous years. Dispensing increased by 7% between 2018 and 2019, 5% between 2017 and 2018 and 3% between 2016 and 2017. This trend may be explained by increased clinician familiarity with this medicine and its use off-label in younger people for treating insomnia and anxiety.

For further information on managing BPSD, see: bpac.org.nz/2020/bpsd.aspx

Figure 9: Number of dispensed prescriptions (per 1,000 registered patients) for zopiclone, benzodiazepines and quetiapine from community pharmacies in New Zealand, 2016 - 2020.

Profile of patients newly initiated or re-initiated on zopiclone, a benzodiazepine or quetiapine, 2018 - 2020

Surprisingly, the number of patients newly initiated or re-initiated* on zopiclone and benzodiazepines was lower in 2020 than previous years ( Figure 10). The majority of patients initiated on zopiclone or a benzodiazepine were of European/Other ethnicity and the dispensing rate generally increased with age ( Figure 11).

* No dispensed prescriptions for these medicines in the previous year

The number of patients newly initiated or re-initiated on quetiapine has been increasing since 2018, although the overall numbers remain small ( Figure 10). The dispensing rate was highest in those aged 20 - 39 years and over 80 years in 2020, which was unchanged from 2018 and 2019 ( Figure 11). Increasing dispensing rates in the older age groups likely reflect its off-label use for managing BPSD, rather than an effect of the COVID-19 pandemic. In younger people, the reason for the increase is less certain, but may relate to increasing off-label use for insomnia or anxiety. ² The highest dispensing rates for quetiapine were in Māori and European/Others ( Figure 11), which was unchanged from previous years and consistent with other reports of antipsychotic prescribing in New Zealand. ²

Figure 10: Number of patients (per 1,000 registered patients) newly initiated or re-initiated on zopiclone, benzodiazepines or quetiapine, 2018 - 2020.

Figure 11: Number of patients (per 1,000 registered patients) newly initiated or re-initiated on zopiclone, benzodiazepines or quetiapine by age and ethnicity, 2018 - 2020.

The number of dispensed prescriptions for medicines used for the management of long-term conditions such as cardiovascular disease, gout and type 2 diabetes is expected to increase over time due to population growth, ageing and increasing rates of co-morbidities. During the COVID-19 pandemic, it was predicted that the lockdown restrictions might result in people delaying primary care appointments or not accessing primary care remotely to request a prescription and therefore not receiving regular prescriptions for their long-term medicines. Encouragingly, this did not seem to be the case.

Type 2 diabetes is a significant health issue in New Zealand, particularly for Māori and Pacific peoples. The number of people diagnosed with type 2 diabetes increases by approximately 3 - 4% each year*. Consequently, dispensing of oral glucose-lowering medicines has also been increasing over time ( Figure 12 and Table 4). The number of dispensed prescriptions for oral glucose-lowering medicines (per 1,000 registered patients) increased by 8% between 2019 and 2020, continuing the upward trend from the previous year (7% increase between 2018 and 2019).

*Based on data from the Virtual Diabetes Register. N.B. The Virtual Diabetes Register does not distinguish between type 1 and type 2 diabetes. Therefore, the estimation of the proportion of type 2 diabetes is based on the assumed ratio of 90% type 2 diabetes to 10% type 1 diabetes. ³

Figure 12: Number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand for selected medicines used in the management of long-term conditions, 2018 - 2020.

The number of dispensed prescriptions for ACE inhibitors and ARBs, allopurinol and statins was also higher in 2020 than in 2019, continuing an upward trend in dispensing from 2018 ( Table 4).

The number of dispensed prescriptions for aspirin decreased by 2% between 2019 and 2020, continuing a downward trend; dispensing decreased by 5% between 2018 and 2019 ( Table 4). The reasons for this decrease may relate to changing evidence about its role in primary prevention of cardiovascular disease, availability of other antiplatelet medicines or people with atrial fibrillation being prescribed an anticoagulant rather than aspirin.

Table 4: Percentage change in the number of dispensed prescriptions (per 1,000 registered patients) from community pharmacies in New Zealand for selected medicines used in the management of long-term conditions, 2018 - 2019 and 2019 - 2020.

Taken together, these data show that the COVID-19 pandemic and associated restrictions did not appear to have a marked negative "pandemic" effect on the dispensing of preventative medicines. A number of factors are likely to underpin this, including many people receiving prescriptions prior to the national lockdown, widespread uptake of telehealth and other technologies to enable patients to access primary care virtually and the pro-active efforts of primary care to contact patients and ensure they had supplies of their regular medicines.

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National report: Overview of national dispensing during 2020

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Twenty-twenty was challenging for everyone, particularly for the health professionals at the front line of New Zealand's response to the COVID-19 pandemic. While New Zealand has experienced low COVID-19 case and mortality rates and few ongoing restrictions compared to many other countries, the effects of the pandemic continue to be felt, e.g.

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Principles for quality and safe prescribing practice

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Principles for quality and safe prescribing practice

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These apply to all prescribers.

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List of Padlets

Resources for Prescribers

Prescribing & common conditions

Prescribing & different populations

Diagnostic Tests

Medications

Antibiotic Stewardship

Wellbeing for prescribers

CPD & updates for prescribers

Cultural Safety & Equity

Playlists & Podcasts

Advanced Clinical Assessment

AI in Healthcare

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Key J. & Hoare K.J., (2020). Nurse prescribing in New Zealand - the difference in levels of prescribing explained. New Zealand Medical Journal. LINK

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This page provides quick summaries of alert signs and symptoms that indicate a more serious underlying pathology. Each article provide a list of red flags, possible causes and advice on history taking and examintion during the consultation and when to refer.

Browse key red flag symptom topics listed A-Z

View red flags by most-recently published here

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Red flag symptoms and clinical signs | GPonline

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This page provides quick summaries of alert signs and symptoms that indicate a more serious underlying pathology. Each article provide a list of red flags, possible causes and advice on history taking and examintion during the consultation and when to refer.

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Create an account to help sift DDx for common acute presentations

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Evaluating Prescribing to Inform Care (EPIC)

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Evaluating Prescribing to Inform Care (EPIC)

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AUT

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Referencing

Referencingis about acknowledging the ownership of resources used in your academic writing, and provides information necessary to identify and retrieve the work cited in the text.

There are many different referencing styles. At AUT most courses use the APA reference style.

What is APA?

APA referencing style is an author-date referencing system published by the American Psychological Association.

There are two components in the APA referencing style: in-text citations and their corresponding reference list entries. With anything that you have read, used and referred to in your academic writing, you must:

acknowledge in text (i.e. in the work / assignment/ essay you are writing)

include in your reference list (i.e. the list at the end of your work of all the sources you refer to)

Reference management software

You may use a reference software to manage your references. The most popular software are EndNote, Mendeley and Zotero.

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Library Guides: APA 7th Referencing Style Guide: Referencing & APA style

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Referencing Referencingis about acknowledging the ownership of resources used in your academic writing, and provides information necessary to identify and retrieve the work cited in the text. There are many different referencing styles. At AUT most courses use the APA reference style. What is APA?

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New Zealand Formulary

New Zealand Formulary for Children

MIMS

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eEML - Electronic Essential Medicines List

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Periapical abscess without sinus Acute malnutrition in infants, children or adolescents (uncomplicated) [children] Acute malnutrition in infants, children or adolescents (complicated) [children] Bacterial pneumonia (Community-acquired pneumonia - mild to moderate) Chronic obstructive pulmonary disease with acute exacerbation gentamicin gentamicin Sepsis without septic shock Bacterial pneumonia (Community-acquired pneumonia - severe) [children]

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Video Tutorial (US but still largely relevant)

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Dr Chris Cameron

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PHARMAC Seminar Series: Medicines in healthcare, 1a. Overview - part 1

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Medicines Regulations 1984 (section 41) Legal requirements for a prescription

Misuse of Drugs Regulations 1977 (section 29) Legal requirements for a controlled drug prescription
Medsafe. (2014). Compliance: Use of Unapproved Medicines and Unapproved Use of Medicines which includes advice on meeting the Health and Disability Services Code of Consumer Rights. LINK

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APA 7th

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This page contains a reference example for an article from the UpToDate database.

Articles in the UpToDate database are available only in that database and have information that changes over time.

In the reference list, format UpToDate articles like periodical articles. Italicize the database name in the reference like a periodical title, but do not italicize the database name if it appears in the text.

Use the year of last update in the date element.

Include a retrieval date because the content is designed to change over time and versions of the page are not archived.

This guidance is new to the 7th edition.

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This page contains a reference example for an article from the UpToDate database. Articles in the UpToDate database are available only in that database and have information that changes over time. In the reference list, format UpToDate articles like periodical articles.

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Lexicomp® Drug Interactions (UptoDate) MASSEY LINK

Martindale: The Complete Drug Reference MASSEY LINK

New Zealand Universal List of Medicines (NZULM)

Medsafe Medicines Information

Pharmac Online Schedule

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Choosing Wisely Canada  Prescribing Cascades LINK

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Health and Disability Commissioner. (2018). Medication Errors.  Complaints closed by the Health and Disability Commissioner: 2009–2016.  LINK

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Dr Chris Cameron

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PHARMAC Seminar Series: Medicines in healthcare, 1b. Overview - part 2

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Massey University

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This section describes the referencing style of the American Psychological Association (APA; 7th edition). If you are new to referencing, see introduction to referencing.

In this section

Related sections

Page authorised by Director, CTL
Last updated on 26 February, 2020

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This section describes the referencing style of the American Psychological Association (APA; 7th edition). If you are new to referencing, see introduction to referencing. Page authorised by Director, CTL Last updated on 26 February, 2020

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Articles in the UpToDate database are available only in that database and have information that changes over time.

In the reference list, format UpToDate articles like periodical articles. Italicize the database name in the reference like a periodical title, but do not italicize the database name if it appears in the text.

Use the year of last update in the date element.

Include a retrieval date because the content is designed to change over time and versions of the page are not archived.

Cochrane reviews follow the journal article format.

Provide the name of the database (Cochrane Database of Systematic Reviews) in italic title case in the reference, but if you write the name of the database elsewhere in the paper, do not italicize it.

Different versions of Cochrane reviews include different information, which means the reference might vary too. Follow the principle of citing what you see.

Full-text versions of Cochrane reviews do not include volume numbers, issue numbers, or article numbers. The full-text version displays when you visit the DOI of the article.

However, the article PDFs show the year as the volume number, an issue number, and an article number.

It is fine to omit the volume, issue, and article number from the Cochrane review reference if the information is missing from your version of the article, but if you do see this information, include it just as you would for any journal article

3. Clinical practice guideline with a group author

Most clinical practice guidelines are published as reports or webpages and so follow the report or webpage reference type, which have the same structure.

Use the committee or agency that developed the guideline in the author element of the reference when no individual authors are credited.

When the title page or cover credits both a committee and an agency, provide the committee name in the author element of the reference and the agency name in the source element of the reference. The first example shows this: The committee is the Healthcare Infection Control Practices Advisory Committee, and the agency is the U.S. Department of Health & Human Services, Centers for Disease Control and Prevention.

When the title page or cover credits only an agency, provide the agency name in the author element of the reference. The second and third examples show this: The National Institute for Health and Care Excellence (NICE) and the World Health Organization are agencies.

Provide the year in which the guideline was developed in the date element of the reference.

If you are citing an updated guideline, use the year of the update in the reference.

Provide the title of the guideline in italic sentence case.

Provide the name of the website from which the guideline was obtained in the source element of the reference.

If the website name is the same as the author, omit the site name to avoid repetition (as in the NICE guideline example).

Provide a URL for the guideline.

4. Clinical practice guideline by individual authors at a government agency, published as part of a series

When a guideline has individual authors, provide the names in the author element of the reference.

Provide the year of the report in the date element of the reference.

Provide the title of the guideline in italic sentence case.

After the title, provide the name of the series (here, Morbidity and Mortality Weekly Report) and volume and issue number for the report in parentheses after the title.

Provide the publisher of the guideline in the source element of the reference.

Provide a URL for the guideline.

The format for drug information is the same as for a webpage.

Provide the name of the drug or pharmaceutical company that manufactures the drug in the author element of the reference.

If a date is not available, substitute "(n.d.)."

Provide the title of the drug information (usually the name of the drug) in italic sentence case, followed by the description "[Drug information]" in square brackets (or other wording as appropriate).

Provide the name of the website from which the drug information was obtained in the source element of the reference. If the website name is the same as the author, omit the site name to avoid repetition.

Provide a URL for the drug information.

6. Lab or diagnostic manual

Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2019). Mosby's diagnostic and laboratory test reference (14th ed.). Elsevier.

Laboratory or diagnostic manuals follow the format for books.

7. Mobile app reference work

For a mobile app reference work with individual authors (as shown in the example), provide the author names in the author element of the reference.

Provide the year of the version used in the date element of the reference.

Provide the title of the app in italic sentence case.

When the app includes an edition number (as with the example), place the edition information in parentheses without italics after the title.

Provide the version number of the app (which you can obtain from the app itself once it is downloaded) in a separate set of parentheses.

Provide the publisher of the app or the name of the app store (e.g., App Store, Google Play Store). In the example, the app was downloaded from the publisher's website, so the publisher (F. A. Davis Company) is provided in the source element of the reference. If you downloaded the app from the App Store instead, use "App Store" instead of "F. A. Davis Company."

Provide a URL when possible.

8. Entry in a mobile app reference work

To cite an entry in a mobile app reference work, follow the format for an edited book chapter.

Provide the author of the app in the author element of the reference. In the example, the company that produces the app (Lexicomp) is treated as a group author.

Provide the date year of the app version that you used in the date element of the reference.

Provide the title of the entry in the reference work in the title element of the reference.

In the source element, provide the name of the app in italics (which in the example happens to be the same as the author), the version of the app used in parentheses, the description "[Mobile app]" and the publisher or app store from which the app was obtained.

Provide a URL when possible.

This guidance is new to the 7th edition.

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Articles in the UpToDate database are available only in that database and have information that changes over time. In the reference list, format UpToDate articles like periodical articles. Italicize the database name in the reference like a periodical title, but do not italicize the database name if it appears in the text.

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Geeky medics

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Pirret, A. M. (2018). Acute care nursing : a physiological approach to clinical assessment and patient care (Third edition). Alison Pirret.
MASSEY LIBRARY LINK

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Respiratory Examination | OSCE Guide | UKMLA | CPSA | PLAB 2

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Full playlist of all examinations

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A collection of awesome video guides demonstrating how to perform various clinical examinations to help you refine your skills and prepare for your exams. Th...

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Heart Murmurs and Heart Sounds: Visual Explanation for Students

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Full playlist neurological exam

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A collection of awesome video guides demonstrating how to perform various neurological examinations (e.g. Cranial nerve examination) to enable you to refine ...

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Interactive tutorial on Literature Searching

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Interactive tutorial on Literature Searching

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Elizabeth Sturrock Massey University Subject Librarian

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Royal Pharmaceutical Society Prescribing Competency Framework (UK)

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Royal Pharmaceutical Society Prescribing Competency Framework (UK)

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PHARMAC Medicines in Healthcare.  This website includes a number of videos about how to prescribe safely

Coles Medical Practice in NZ Ethical and evidence-based practice guidance in NZ

Choosing Wisely Provides links and information about choosing the right test at for the right reason

Health Quality & Safety Commission New Zealand A number of resources for safe prescribing

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Geeky Medics Clinical Examination Series

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Geeky Medics Clinical Examination Series

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Clinical Examination | OSCE Guides | Geeky Medics

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A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes.

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How to Create a Differential Diagnosis PART 1

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How to Create a Differential Diagnosis (Part 1 of 3)

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Hopcroft, K., & Forte, V. (General practitioner). (2020). Symptom sorter. [electronic resource] (Sixth edition). CRC Press/Taylor & Francis Group.

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Bergl, P. A., Manesh, R., Basel, D., & Olson, A. (2019). Keeping a Flexible Differential Diagnosis: an Exercise in Clinical Reasoning. Journal of general internal medicine, 34(6), 1063–1068. https://doi.org/10.1007/s11606-019-04867-1

Gilliam, S. (2019). Elevating diagnostic skills with logical reasoning. Nurse Practitioner, 44(5), 51-55. https://doi.org/10.1097/01.NPR.0000554675.55073.5a

Pirret, A. M., Neville, S. J., & La Grow, S. J. (2015). Nurse practitioners versus doctors diagnostic reasoning in a complex case presentation to an acute tertiary hospital: A comparative study. International Journal of Nursing Studies, 52(3), 716-726. https://doi.org/10.1016/j.ijnurstu.2014.08.009

Pirret, A. M. (2016). Nurse Practitioners’ Versus Physicians’ Diagnostic Reasoning Style and Use of Maxims: A Comparative Study [Article]. The Journal for Nurse Practitioners, 12(6), 381-389. https://doi.org/10.1016/j.nurpra.2016.02.006

Rajkomar, A., & Dhaliwal, G. (2011, Summer). Improving diagnostic reasoning to improve patient safety. The Permanente journal, 15(3), 68-73. https://doi.org/10.7812/tpp/11-098 LINK

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Horeczko T, (Producer) (2018 December) List or Gist? Inductive Clinical Decision Making: a PEM Primer

Horeczko T, (Producer) (2018 November) Harpoon or Hook? Deductive Clinical Reasoning: a PEM Primer

Horeczko T, (Producer) (2019 January) Guess or Process? Abductive Reasoning: a PEM Primer

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How to Create a Differential Diagnosis PART 2

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How to Create a Differential Diagnosis (Part 2 of 3)

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How to Create a Differential Diagnosis PART 3

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How to Create a Differential Diagnosis (Part 3 of 3)

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Medical Council of New Zealand. (2016). Good prescribing practice LINK  NCNZ do not have an equivalent but directed me to this (more useful for NPs).

Maxwell, S.R.J.. (2016). Rational prescribing: The principles of drug selection. Clinical Medicine, Journal Of The Royal College Of Physicians Of London, 16(5)

Bpac NZ. (2015). Piles of pills: Prescribing appropriate quantities of medicines.  LINK

Pollock, M., Bazaldua, O. V., & Dobbie, A. E. (2007, Jan 15). Appropriate prescribing of medications: an eight-step approach. Am Fam Physician, 75(2), 231-236. LINK

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Interactive Tutorial on using Decision Support Tools

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Interactive Tutorial on using Decision Support Tools

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Elizabeth Sturrock Massey University Subject Librarian

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Nurse Prescribing Clinical Support Tools and Drug Resources

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Abdominal Examination - OSCE Guide (New Release)

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Everyone strives to define themselves as an individual, distinguished from the crowd and defined by their own desires and experiences. We are exactly this: biologically unique, and (with the exception of identical twins) the owners of a distinct pattern of DNA unlike anyone else's (Box 1: 'Creating an individual'). It therefore seems antiquated, in a world more accepting of difference than ever before, to accept a universal, generalised idea of how a person will respond to a drug.

Pharmacogenomics involves the investigation of the effects of genetic variation, the differences in our genome, on drug response. Pharmacogenomics aims to improve the safety and effectiveness of drug treatment by using genetic information to inform prescription decision making, similarly to how renal function is taken into account when prescribing drugs that are eliminated by the kidneys. In this process, genetic variants that influence drug response are identified, characterised and then used to stratify patients into subgroups that receive subgroup-specific, genotype-informed prescriptions. Therefore, pharmacogenomics is a cornerstone in the ongoing endeavour for precision medicine, also known as stratified or personalised medicine.

The term 'pharmacogenetics' was first coined by the German geneticist Friedrich Vogel in 1959 and relates to the study of inherited genetic differences in drug metabolic pathways that can affect individual responses to drugs, both in terms of therapeutic effect as well as adverse effects. However, the concept that innate factors can affect drug response dates back as far as Pythagoras. Pharmacogenomics is often used interchangeably with pharmacogenetics, and was first used in 1997.

Current prescribing approaches include a degree of individual tailoring based on factors such as age, weight, biochemical markers and co-morbidities. However, despite these considerations some patients do not respond in the expected manner. The number of patients who respond beneficially to a given drug can be anything between 25% and 80%. Furthermore, around 6% of hospital admissions are related to an adverse drug reaction (ADR), and drug tolerability issues are associated with poor medication adherence. Pharmacogenomics aims to offer clinical decision support to improve the benefit-risk profile of prescribed medications.

Box 1: Creating an individual

The human genome is the instruction manual for building a person. DNA, the language of the text, comprises sequences of nucleotide bases that are split into sections known as genes. Each gene is responsible for encoding the information to create a specific protein.

The genome remains largely similar from person to person with small variations, known as polymorphisms, present in everyone. These polymorphisms are either germ-line (inherited) or somatic (acquired).

An allele is a variant form of a gene caused by a polymorphism. If a specific allele occurs in less than 1% of a population, it is typically termed a mutation. While many polymorphisms do not significantly alter gene function, some affect gene expression or the structure and ultimately the activity of the encoded protein. These are of particular interest with regard to diagnostics and therapeutics.

These instructions are also influenced by 'epigenetic' modifications that can influence gene expression via mechanisms such as switching off an activated gene. These modifications can be due to factors such as age, lifestyle or disease and can result in potential alterations to the expression of phenotypes without changing the underlying genotype.

What makes up a chromosome?

Source: The Pharmaceutical Journal

The genetics of drug response

The identification of mutations is also being used to design new drugs that must be used in patients with that mutation. This is most relevant in cancer medicine, where pharmacogenomics currently has, and will have, increasing relevance. For example, vemurafenib was designed to inhibit the V600E mutation in the BRAF gene in metastatic malignant melanoma. The use of targeted therapies, such as trastuzumab, in HER2-positive breast cancer is another example. Similar approaches are now also being used for the germline genome. Ivacaftor is a novel therapeutic licensed for patients with cystic fibrosis (CF) carrying certain pathogenic mutations in the CF faulty protein, CFTR. Ivacaftor binds to and partially restores the activity of CFTR, but only works in patients carrying specific CFTR mutations, and thus requires a knowledge of the genotype before prescribing.

P450 genes

The effect of environmental influences on CYP metabolising activity and drug response is extensively covered in the pharmacy curriculum (e.g. drug-drug and drug-food interactions). However, a large number of CYP genes are polymorphic and, therefore, the influence of genetics on variation in response should not be underestimated.

The term 'metaboliser phenotype' is often used when predicting the activity of a drug-metabolising enzyme in an individual patient, based on the gene alleles the patient carries and prior knowledge of the typical activity level of each allele. However, some enzymes, such as CYP2D6, lead to four different activity phenotypes: poor metaboliser, intermediate metaboliser, extensive (normal) metaboliser and ultra-rapid metaboliser.

More than 100 different CYP2D6 allelic variants have been recorded to date. Around 6-10% of Caucasians are considered poor metabolisers; however, the incidence varies among ethnic groups with less than 1% of Asians and 2-5% of African-Americans lacking the enzyme. CYP2D6 is responsible for the metabolism and/or activation of around 25% of prescribed drugs, including for example, codeine. Codeine is a prodrug and a small proportion (around 0-15%) undergoes O-demethylation to morphine in the liver via CYP2D6
. However, because of the polymorphic nature of CYP2D6, the combination of alleles present can determine the extent to which this occurs. Importantly, the CYP2D6 ultra-rapid metaboliser phenotype (where there are more than two copies of the gene) has been associated with fatal cases of opiate toxicity in patients administered codeine, resulting from increased codeine biotransformation to morphine. This prompted the European Medicines Agency (EMA), the body that evaluates medicinal products for use in Europe, to review codeine use and led to the current restrictions by the Medicines and Healthcare Products Regulatory Agency (MHRA), the regulatory body for medicines and medical devices in the UK. Around 2% of Caucasians are ultra-rapid metabolisers, while 29% of Ethiopians carry more than two copies of the gene.

Identification of poor metabolisers is also important to circumvent issues such as clopidogrel resistance. Like codeine, clopidogrel is a prodrug that requires biotransformation into the active thiol group-containing moiety that inhibits ADP-induced platelet activation. The degree of platelet inhibition among individuals taking clopidogrel is highly variable, and this can potentially result in life-threatening sequelae such as stent thrombosis. CYP2C19 is one of the principal enzymes involved in clopidogrel activation and around 3-5% of Caucasians are deemed poor metabolisers, rising to 12% to 23% of the Asian population. The Food and Drug Administration (FDA), the body responsible for evaluating the safety and efficacy of medicines in the United States, issued a black box warning in 2010 advising about this association.

Transporter genes

In addition to determining enzyme function, polymorphisms also affect drug transporter proteins, structures responsible for the movement of ions and molecules across biological membranes. SLCO1B1, a gene encoding a protein known as OATP1B1, responsible for the intrahepatic transport of multiple compounds, including statins. Some SLCO1B1 variants have been associated with lower uptake of statins (in particular, simvastatin), increased drug exposure, and a higher risk of simvastatin intolerance and myopathy.

Pharmacogenomics facilitates insight into the underlying mechanisms of ADRs and can predict susceptibility to some idiosyncratic (type B) ADRs. An important class of genes are the human leukocyte antigens ( HLA); specific HLA alleles can increase susceptibility to immune-mediated idiosyncratic ADRs through off-target mechanisms. An example is the effect of HLA-B*57:01 on abacavir hypersensitivity. The summary of product characteristics (SPC) for abacavir mandates HLA-B*57:01 typing before the use of abacavir. This is also mentioned in guidelines from organisations, such as the British HIV Association, who recommend pre-emptive HLA genotyping to identify high-risk individuals. Another example is the association of HLA-B*15:02 with carbamazepine-induced toxic epidermal necrolysis; this HLA allele is particularly prevalent in Southeast Asian countries.

Improving patient outcomes is just one of the potential benefits of pharmacogenomics. In an environment of increasing demand and limited resources, the projected annual costs to the NHS of medication-related hospital admissions is around £466m with a further £300m spent on unused medications.

A personalised prescribing approach strives to reduce ADRs and ineffective prescriptions to provide a smarter, more cost-effective way to manage the medicines budget. However, implementation of such innovative approaches has many challenges.

Barriers to implementation

Recent decades have seen multiple advances within the field of genomics; not least the completion of the Human Genome Project in 2003. This milestone and the statement of requirement for a 'genetically literate' primary care workforce by the Human Genetics Commission set high expectations for a paradigm shift towards genomics becoming routine in clinical care, spearheaded by pharmacogenomics. However, nearly 14 years later, even the integration of pharmacogenomics into standard clinical practice overall has been limited.

Finally, deficits in prescriber knowledge surrounding translating genetic information into clinical action points may also contribute to the poor uptake of testing. Ongoing efforts to collate evidence and information for clinical utilisation have been fruitful and the Pharmacogenomics Knowledgebase provides a repository of pharmacogenomic-based drug dosing clinical guidelines from multiple sources including the Clinical Pharmacogenetics Implementation Consortium (CPIC) and Dutch Pharmacogenetics Working Group (DPWG).

Moving to the future

This transition has forced the industry to view its role beyond solely the manufacture of the therapeutic and into the realms of companion diagnostics. These kits and assays allow precision medicine to be truly effective by identifying, as accurately as possible, the patient's underlying disease mechanism or predictive biomarkers. Such technologies are already being used in clinical practice, with regulatory agencies approving cetuximab to be used as part of the first-line regime for KRAS mutation-negative (wild-type) Epidermal Growth Factor Receptor (EGFR)-expressing metastatic colorectal cancer as well as approving the first KRAS companion diagnostic test kit, the QIAGEN Therascreen.

It is important to recognise, however, that while the germline genome remains constant over a lifetime, gene expression levels may change. The realisation of personalised medicine will require holistic assessment of the patient that will include not only genomics, but also environmental factors, disease status and age-related changes.

In the UK, the NHS outlined its plans for integration of personalised medicine in 2016, aiming for whole-genome sequencing to be standard for specific conditions by 2020. The advent of the 100,000 Genomes Project and the sale from retail pharmacies of the home genetics kit, 23andMe Â®
, are further indicators of the need for pharmacists, in all areas of the profession, to become familiar with the principles of pharmacogenomics and its evolving application into clinical practice.

Financial and conflicts of interest disclosure:

The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. No writing assistance was used in the production of this manuscript.

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Pharmacogenomics: an overview - The Pharmaceutical Journal

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With the NHS working towards the integration of personalised medicine, in particular, aiming for whole-genome sequencing to be standard for specific conditions by 2020, it is important for pharmacists and healthcare professionals to be aware of the principles of pharmacogenomics and its evolving application into clinical practice.

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Diagnosaurus APP   APPLE APP  ANDROID APP

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Conn, R. L., Dornan, T., Shields, M. D., Kearney, O., & Tully, M. P. (2019, 08 / 01 /). What causes prescribing errors in children? Scoping review. BMJ Open, 9(8). https://doi.org/10.1136/bmjopen-2018-028680

Kunac, D. L., Tatley, M. V., & Seddon, M. E. (2014, 01/01/). A new web-based medication error reporting programme (MERP) to supplement pharmacovigilance in New Zealand - findings from a pilot study in primary care. New Zealand Medical Journal.

Robb, G., Loe, E., Maharaj, A., Hamblin, R., & Seddon, M. E. (2017). Medication-related patient harm in New Zealand hospitals. The New Zealand medical journal, 130(1460), 21-32.

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Include the title of the blog message post as well as the URL. You do not italicize the titles for items in online communities such as blogs, newsgroups or forum. If the author's name is not available, provide the screen name.
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References:
MiddleKid. (2007, January 22). Re: The unfortunate prerequisites and consequences of partitioning your mind. Science. http://scienceblogs.com/pharyngula/2007/01/the_unfortunate_prerequisites.php

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Research Guides: APA Citation Style, 7th edition: Blog post

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Updated guidance 2021

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Process for the licensing of medication in NZ

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Process for the licensing of medication in NZ

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Medsafe

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Medsafe's Evaluation and Approval Process

How are medicines approved in New Zealand?
How can I know that a medicine has been approved for sale in New Zealand?
What is the medicine evaluation process?
How long does this process take?
What data does Medsafe review in medicine applications?
What are the criteria used by Medsafe to establish the quality of a medicine?
How is the efficacy of a medicine established before it can be approved?
How is the safety of a medicine established before it is approved for use in New Zealand?

How are medicines approved in New Zealand?

Companies who wish to sell a new medicine in New Zealand make an application to Medsafe (called a New Medicine Application or NMA). This application includes information that demonstrates the medicine meets New Zealand and internationally recognised standards for quality, safety and efficacy.

Medsafe reviews this information and makes a recommendation to the Minister as to whether the medicine is approvable, or otherwise. If the medicine is approved, the New Zealand sponsor company then decides if the medicine will be supplied in this country.

Companies also submit notifications to Medsafe for planned material changes to an approved medicine (called a Changed Medicine Notification or CMN). Medsafe evaluates the change(s) to ensure that it does not affect the established quality, safety and efficacy of a registered medicine. Changed medicines cannot be marketed without the consent of the Director-General of Health (or delegate).

Medsafe is not responsible for funding or purchasing medicines in New Zealand. The government organisation responsible for determining which medicines will be publicly funded is PHARMAC.
Visit the PHARMAC website.
How can I know that a medicine has been approved for sale in New Zealand?

Medsafe lists all medicines that have been approved in New Zealand on its website, and any medicines where an application was submitted but approval was not granted.

This list includes information on where the medicine is made, the ingredients it contains, how it is packaged, what it is used for (indications) and who is legally responsible for the product (known as the Sponsor).

This information can be found on the Product/Application Search page.

What is the medicine evaluation process?

An application to approve a new medicine includes data supporting the medicine's quality, safety and efficacy.

An evaluation of the New Medicine Application is undertaken. If Medsafe considers the information to be inadequate it will request further information. Medsafe then reviews the response and makes a decision as to whether or not it can recommend to the Minister of Health that the medicine be granted consent to be marketed in New Zealand.

How long does this process take?

Medsafe aims to complete the various stages of a New Medicine Application evaluation within target time frames. There are also statutory timelines for the evaluation of Changed Medicine Notifications. The total time taken to reach a final decision can vary, and depends on the amount and complexity of the information provided, the amount of additional information requested and how long it takes the company to respond to Medsafe's requests for more information.

Information on Medsafe's evaluation timelines.

What data does Medsafe review in medicine applications?

The acceptability of the proposed product trade name.

Evidence of Good manufacturing practice (GMP) to demonstrate the medicines are consistently manufactured under acceptable quality standards.

Chemical and biological data that supports the source, manufacture, characterisation, quantity, quality, storage and stability of the drug substance (active ingredient) and drug product (finished product).

The quantity and quality of other non-active ingredients (excipients) present in the medicine.

The formulation of the medicine (eg, tablet, suspension, capsule, injection).

Agreed specifications (quality tests) that the medicine must meet before it is released to be sold or dispensed.

Results of bioequivalence studies that evaluate the therapeutic equivalency of generic medicines and the corresponding brand name (innovator) products.

Results of clinical studies in people that demonstrate new medicines are safe and effective for the treatment of a particular disease or condition.

The quality of the medicine's packaging and the content of the medicine label.

The information presented in the medicine data sheet and package insert (eg, consumer medicine information (CMI)).

What are the criteria used by Medsafe to establish the quality of a medicine?

Medsafe assesses medicine applications against internationally established criteria, such as guidelines published by the EMA (European authority), the FDA (USA), Health Canada, the TGA (Australia) and the International Conference on Harmonisation (ICH).

Medsafe does not test every medicine before it is approved. The assessment of a medicine application is based on information supplied to Medsafe. Manufacturers are regularly inspected by Medsafe or other international regulators to ensure they consistently produce high quality medicines.

All medicines, regardless of the country of manufacture, are assessed to the same requirements.

How is the efficacy of a medicine established before it can be approved?

Efficacy is a technical term used to describe how well the medicine works.

Clinical trials are undertaken by pharmaceutical companies to collect data on the efficacy of potential new medicines. These trials can be conducted using healthy volunteers or patients, depending on the type of medicine and its stage of development.

Clinical trials begin with small studies in a controlled population of volunteers or patients and, as data are gathered, expand to large scale studies in patients. These large scale studies investigate the new medicine in comparison with placebo or another established treatment.

Bioequivalence studies are designed to compare the rate and extent of absorption of the active ingredient(s) in a test generic medicine with that of a reference innovative medicine. If two medicines are demonstrated to be bioequivalent, it is considered that there would be no clinically significant difference in their bioavailability, and their efficacy and safety profiles are therefore considered to be the same. As a result, it would not normally be necessary to repeat clinical studies for generic medicines.

How is the safety of a medicine established before it is approved for use in New Zealand?

The pharmaceutical company responsible for that medicine provides Medsafe with safety information from clinical studies performed using that medicine. If the medicine has also been supplied elsewhere the company will also provide data from use in that country. The extent of the clinical studies varies depending on the type of medicine application.

Medsafe evaluates the results from these clinical studies to determine if the safety profile is acceptable.

Medsafe reviews the risks and benefits for each specific medicine to ensure that the safety profile is acceptable (ie, the benefits of the medicine outweigh the risks).

The following factors are taken into consideration.

1. Benefits

Has efficacy been demonstrated in the target population (ie, those who will use the medicine)?

Is the medicine significantly better than a placebo?

How does the medicine compare to any alternative treatments?

How many people have the condition that this medicine will treat or prevent?

What is the natural history of the disease?

Is it self-limiting, chronic or fatal?

2. Risks

What proportion of people taking the medicine experience an adverse reaction?

How many of these adverse reactions are considered to be serious?

How many people stopped treatment because of an adverse reaction?

Are the adverse reactions reversible, treatable or avoidable (eg, interactions with other medicines)?

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Medsafe's Evaluation and Approval Process

# data[].attributes.attachment_link.description
How are medicines approved in New Zealand? How can I know that a medicine has been approved for sale in New Zealand? What is the medicine evaluation process? How long does this process take? What data does Medsafe review in medicine applications? What are the criteria used by Medsafe to establish the quality of a medicine?

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Health Practitioners Competence Assurance Act 2003 (HPCA) The intent of the HPCA aims to protect the public from harm at the hands of health care professionals (HCP).  It delegates the responsibility for enacting this to Responsible Agencies (RAs) for each profession.  The RA for nursing is the Nursing Council of New Zealand. Under the HPCA, the titles of HCP may only be used by those who have met the standards of and are currently registered with the relevant RA.

Medicines Act 1981 Defines the terms medicine, new medicine, prescription medicine, and restricted medicine. Regulates medicines, related products and medical devices in New Zealand.  It also the legislative framework for prescribing prescription medicines and the groups of health professionals able to prescribe (includes definitions of authorised and designated prescribers).

Medicines Regulations 1984 Outlines the classification of medicines, and lists the medicines in each category.  It also regulates the quality, advertising, labelling, production, transport, prescribing & dispensing conditions, licensing, withdrawal, data sheets and includes schedule of medicines.  Section 41 outlines the legal requirements for all prescriptions.

Standing Orders Regulations 2002A Standing Order is a generic prescription that allows non-prescribing health professionals to make drug administration decisions as per prescribed criteria.  Authorised prescribers can issue and oversee standing orders, designated prescribers cannot.

Medicines (Designated Prescriber: Nurse Practitioners) Regulations 2005 now revoked and replaced section 51(a) of the Medicines Amendment Act 2013 (2013 No 141).

Medicines (Designated Prescriber—Registered Nurses Practising in Diabetes Health)Regulationsnow revoked and covered by The Medicines (Designated Prescriber-Registered Nurses) Regulations 2016

Medicines Amendment Act 2013 (amends the Medicines Act 1981) - Added nurse practitioners to the list of authorised practitioners who can prescribe medicines that lie within their scope of practice – giving them equivalence to doctors, dentists and midwives.

The Medicines (Designated Prescriber-Registered Nurses) Regulations 2016 - The purpose of these regulations is:—

·       to authorise registered nurses who meet specified requirements for qualifications, training, and competence to be designated prescribers for the purpose of prescribing specified prescription medicines; and

·       to provide for the qualifications, training, and competence requirements; and

·       to prohibit registered nurses from prescribing specified prescription medicines if they fail to comply with the requirements; and

·       to make non-compliance with the requirements an offence.

Misuse of Drugs Act 1975 Legislative framework for controlled drugs.

Misuse of Drugs Regulations 1977 Outlines licensing, permissions, restrictions and prescribing of controlled drugs.  Allows designated nurse prescribers (primary and specialty care) to prescribe specified controlled drugs from Schedule 1A.  Section 29 Sets out requirements for controlled drug prescriptions.

Amendment to the Misuse of Drugs Regulations 2014 Designated prescribers may prescribe from Schedule 1A only.  Regulation 29 updated requirements for controlled drug prescriptions to include electronic prescriptions (approved).

Misuse of Drugs Amendment Act 2016 Sets out the circumstances under which patients with addictions may be prescribed controlled drugs (generally only for those working in addition services and after specific application).

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YouTube Channels/Playlists & Podcasts

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Proctor, J., & Rickards, E. (2020). How to perform chest auscultation and interpret the findings. Nursing Times, 116(1), 23–26.

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Principles for Quality & Safe Prescribing Practice

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