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Bansal S, Alvarez Del Castillo Gonzalez J, Chuluunbaatar Y, Brodie A. Insights and Recommendations From Two Urology-Based Educational Interventions: Development of a Urology Teaching Programme and Out-of-Hours Urology Handbook. Cureus 2023; 15:e46849. [PMID: 37954801 PMCID: PMC10637326 DOI: 10.7759/cureus.46849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Exposure and education in urology for medical students (MSs) and junior doctors (JDs) have long been overlooked, resulting in inadequate preparedness for the management of urological cases/patients. This study addresses this deficiency through the implementation of a Urology Teaching Programme (UTP) and the creation of an Out-of-Hours Urology Handbook (OOHUH). The UTP was delivered virtually, targeting senior MSs and JDs, and covered common urological presentations and management pathways from a JD's perspective. The OOHUH aimed to enhance the care provided by general surgery senior house officers (SHOs) at Lister Hospital (Stevenage, UK), offering guidance for nine common urological conditions in emergency and out-of-hours settings. Both initiatives demonstrated significant improvements in knowledge and confidence in urology. The findings underscore the importance of supplementary urology education and suggest strategies for bridging training gaps in medical curricula and clinical practice. Recommendations include tailored induction programs and simulation days for junior doctors, along with the widespread adoption of such educational interventions to enhance patient care and trainee preparedness in urology.
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Affiliation(s)
| | | | | | - Andrew Brodie
- Department of Urology, Lister Hospital, Stevenage, GBR
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Shi W, Qin H, Vaughan B, Ng L. Educational Interventions for Medical Students to Improve Pharmacological Knowledge and Prescribing Skills: A Scoping Review. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:348-360. [PMID: 37662713 PMCID: PMC10473179 DOI: 10.5334/pme.1006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/24/2023] [Indexed: 09/05/2023]
Abstract
Introduction Medication-related errors place a heavy financial burden on healthcare systems worldwide, and mistakes are most likely to occur at the stage of prescribing. Junior doctors are more likely to make prescribing errors, and medical graduates also lack confidence and preparedness towards prescribing. Thus, this review aimed to evaluate the existing educational approaches to improve pharmacological knowledge and prescribing skills among medical students. Methods CENTRAL, CINAHL, ERIC, Ovid Embase, Ovid MEDLINE, Ovid PsycINFO, and Scopus were searched with keywords related to "pharmacological knowledge", "prescribing skills", "educational interventions" for articles published since 2016. Results 3595 records were identified, and 115 full-text articles were assessed for eligibility. Eighty full-text articles were eligible and included in this review. Thirty-seven studies focused on improving prescribing skills, whilst 43 targeted pharmacological knowledge. A broad range of interventions was implemented, including e-learning, case-based, interprofessional, and experiential learning. Pharmacological knowledge and prescribing skills were measured in various ways, and all studies reported one or more positive findings at Kirkpatrick level 1 or 2. No study reported outcomes at Kirkpatrick levels 3 and 4. Discussion The World Health Organisation's Good Guide to Prescribing was the foundation of the development of prescribing educational interventions. Emerging interventions such as experiential and interprofessional learning should be incorporated into the prescribing curriculum. Innovative approaches such as game-based learning can be considered for clinical pharmacology teaching. However, there was a lack of outcomes at Kirkpatrick levels 3 and 4. Robust methodology and reliable outcome measures are also needed in future studies.
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Affiliation(s)
- Weiwei Shi
- Melbourne Medical school, The University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Qin
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brett Vaughan
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louisa Ng
- The University of Melbourne, Melbourne Medical school, and Department of Medical Education, Australia
- Department of Rehabilitation Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Towers A, Dixon J, Field J, Martin R, Martin N. Combining virtual reality and 3D-printed models to simulate patient-specific dental operative procedures-A study exploring student perceptions. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2022; 26:393-403. [PMID: 34498360 DOI: 10.1111/eje.12715] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/06/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Students face a number of challenges in translating the skills acquired in pre-clinical simulation environments to the delivery of real patient care. These are particularly emphasised for complex operative procedures such as tooth preparations for indirect restorations. This paper reports student perceptions of a novel approach designed to improving student confidence when undertaking operative procedures on patients for the first time, by providing patient-specific simulation using virtual reality (VR) and 3D-printed models of the student's real clinical case. MATERIALS AND METHODS Students practised on patient-specific models, in the presence of a clinical tutor, firstly using VR simulation then with 3D-printed models in a clinical skills laboratory. The students then carried out the operative procedure on their patients, on the third occasion of practice. After providing the treatment for their patients, students attended a semi-structured interview to discuss their experiences. The qualitative data were analysed using two forms of inductive analysis. RESULTS Students most frequently cited: the value of the educator, increased confidence and efficiency during the clinical procedure, improved patient confidence and the complementary benefits of the two simulation modalities. Thematic analysis of participants' responses uncovered five key themes: The value of virtual reality dental simulators The value of clinical skills laboratory simulation with 3D-printed models The value of educator engagement The impact on the clinical procedure and the patient The VR and clinical skills laboratory balance CONCLUSION: This paper reports the early findings of an intervention that improves dental student confidence through the use of patient-specific VR exercises and 3D-printed models. These provided an incremental learning experience for an operative clinical procedure, prior to treatment of the live patient. Early results suggest this is a positive experience for the students, providing a valuable contribution to their confidence and preparedness.
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Affiliation(s)
- Ashley Towers
- The University of Sheffield, School of Clinical Dentistry, Sheffield, UK
| | - Jonathan Dixon
- The University of Sheffield, School of Clinical Dentistry, Sheffield, UK
| | - James Field
- Cardiff University, School of Dentistry, Cardiff, UK
| | - Rachel Martin
- The University of Sheffield, School of Clinical Dentistry, Sheffield, UK
| | - Nicolas Martin
- The University of Sheffield, School of Clinical Dentistry, Sheffield, UK
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Hajj A, Azzo C, Hallit S, Salameh P, Sacre H, Abdou F, Naaman N, Khabbaz LR. Assessment of drug-prescribing perception and practice among dental care providers: a cross-sectional Lebanese study. Pharm Pract (Granada) 2021; 19:2234. [PMID: 33777263 PMCID: PMC7979316 DOI: 10.18549/pharmpract.2021.1.2234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/28/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Dentists play an essential role in providing high-quality dental care, taking
into consideration the clinical context and concomitant medications taken by
the patients. Objective: This study aimed to assess drug-prescribing perception and practices in
addition to drug-related educational needs among Lebanese dentists; it also
evaluated the need for interprofessional collaboration between dentists and
pharmacists. Methods: An exploratory cross-sectional study using an online questionnaire targeted a
sample of dentists from all Lebanese districts. Participants gave their
consent by accepting to complete the survey (ethics approval reference:
USJ-2016-63). The questionnaire consisted of closed-ended questions
exploring: 1) drug-prescribing perception, 2) drug-prescribing practice, and
3) collaboration with pharmacists regarding their respective roles in
providing appropriate counseling to patients. Two indexes were created: the
first evaluated self-confidence in prescribing medications, and the second
assessed dentists’ confidence in pharmacists. Logistic regressions
were performed, taking each index as a dependent variable. Results A total of 137 dentists completed the survey (59% females; mean age:
42.17; SD: 13.78 years). The majority had a fair to good perceived knowledge
in pharmacology and therapeutics (80.3%), only 30.7% reported
to be sufficiently equipped to prescribe safely. Dentists exhibited
particularly low perceived knowledge about prescribing in elderly patients,
dosing, medication use in pregnancy, drug interactions, and adverse
reactions. Dentists specialized in periodontics had the lowest odds of
having self-confidence in prescribing drugs (aOR=0.25; p<0.001).
Also, 64.3% declared that they routinely check a reference source
before prescribing, and 78% relied on pharmaceutical companies and
medical representatives to get information on medications. While 61%
declared that pharmacists should provide oral care counseling, only half of
them encouraged their patients to talk to their pharmacists about their
medications. Only 15% considered that patients are getting enough
counseling from the pharmacist, with a global confidence index below the
median value, suggesting the need for more collaboration, especially with
periodontists who exhibited the lowest confidence in pharmacists
(aOR=0.45). Conclusions Lebanese dentists reported some lack of knowledge and confidence in
prescribing practices. Education, training, and close collaboration between
pharmacists and dentists are essential to overcome these problems and avoid
potential harm to patients.
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Affiliation(s)
- Aline Hajj
- PharmD, PhD. Laboratory of Pharmacology, Clinical Pharmacy and Drug Quality Control, Faculty of Pharmacy, Saint-Joseph University . Beirut ( Lebanon ).
| | - Christel Azzo
- PharmD. Laboratory of Pharmacology, Clinical Pharmacy and Drug Quality Control, Faculty of Pharmacy, Saint-Joseph University . Beirut ( Lebanon ).
| | - Souheil Hallit
- PharmD, PhD. Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK) . Jounieh ( Lebanon ).
| | - Pascale Salameh
- PharmD, PhD. School of Medicine, University of Nicosia . Nicosia ( Cyprus ).
| | - Hala Sacre
- PharmD. National Institute of Public Health, Clinical Epidemiology, and Toxicology-Lebanon (INSPECT-LB) . Beirut ( Lebanon ).
| | - Frederic Abdou
- PharmD. Laboratory of Pharmacology, Clinical Pharmacy and Drug Quality Control, Faculty of Pharmacy, Saint-Joseph University . Beirut ( Lebanon ).
| | - Nada Naaman
- DDS, PhD. Faculty of Dental medicine, Saint-Joseph University . Beirut ( Lebanon ).
| | - Lydia R Khabbaz
- PharmD, PhD. Laboratory of Pharmacology, Clinical Pharmacy and Drug Quality Control, Faculty of Pharmacy, Saint-Joseph University . Beirut ( Lebanon ).
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Carlsson T, Winder M, Eriksson AL, Wallerstedt SM. Student Characteristics Associated with Passing the Exam in Undergraduate Pharmacology Courses-a Cross-sectional Study in Six University Degree Programs. MEDICAL SCIENCE EDUCATOR 2020; 30:1137-1144. [PMID: 34457776 PMCID: PMC8368336 DOI: 10.1007/s40670-020-01026-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Adequate knowledge in pharmacology is crucial in many professions but a non-negligible proportion of students fail the exams and knowledge of underlying factors is largely lacking. This study was performed to evaluate to what extent various factors are related to student performance in pharmacology-related courses in higher education, linking administrative data to attendance at non-mandatory teaching sessions and questionnaire replies. A total of 596 students (median age: 22 years; 70% female) were included from eight courses which are part of either the medical, pharmacy, dentistry, nursing, or biomedical analyst degree programs at the Sahlgrenska Academy, Gothenburg, Sweden. In all, 380 (64%) students passed the regular program- and course-specific exam. Multivariate logistic regression analysis revealed that a high participation rate in non-mandatory teaching sessions, as well as a perceived great interest in pharmacology, was associated with students' passing of the exam; adjusted odds ratio (95% confidence interval): 1.30 (1.19 to 1.42; per 10 percentage unit increase in attendance) and 3.38 (1.86 to 6.12), respectively. Working for wages during the course weeks and pre-university grades used in the program application were significant factors in subgroups of students, negatively and positively associated with the exam results, respectively. Age, having Swedish as a second language, and time spent studying were only associated with the exam result in the univariate analyses. To conclude, both students and teachers can contribute significantly to successful education within pharmacology, students by participating in the teaching sessions and teachers by encouraging students to find the subject interesting.
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Affiliation(s)
- Thomas Carlsson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, SE-405 30 Gothenburg, Sweden
| | - Michael Winder
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, SE-405 30 Gothenburg, Sweden
| | - Anna L. Eriksson
- Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanna M. Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, SE-405 30 Gothenburg, Sweden
- HTA Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
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Merchant H, Nyamapfene T. An evaluation of educational interventions aimed at preparing medical students for discharge summary writing: a rapid review of the literature. Ir J Med Sci 2020; 190:523-530. [PMID: 32725348 DOI: 10.1007/s11845-020-02325-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/23/2020] [Indexed: 11/25/2022]
Abstract
Whilst discharge summaries are important for ensuring patient continuity of care, they often lack important information. Medical students and newly qualified doctors have attributed this to insufficient teaching, thereby indicating a need to improve discharge summary education within the undergraduate medical curriculum. The aim was to review educational approaches used to prepare undergraduate medical students for discharge summary writing, and their effectiveness Medline and Scopus were systematically searched using keywords, for studies published between 2009 and 2019. Narrative synthesis was used to integrate the findings of the included studies. Study quality was appraised using the Medical Education Research Study Quality Instrument. Six studies were included in this review. Allowing students to write a discharge summary following a real patient encounter and receive written feedback was the most common educational approach used (n = 4). Three of these studies improved student attitudes towards discharge summary writing. One study described the use of a mobile application, which improved discharge summary quality. Another study utilized interprofessional learning but the effect was statistically insignificant. Medical Education Research Study Quality Instrument scores were satisfactory (mean = 12, range = 8.4-15). The literature concerning this topic is limited. The results indicate that providing written feedback to students can positively influence attitudes towards discharge summary writing. Optimisation of the quality of discharge summaries written by medical students using feedback and checklists requires further investigation, as does the use of interprofessional learning. Future studies would additionally benefit from including participant baseline data and control groups, being multicentred and measuring behavioural or patient/healthcare outcomes.
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Chaudhuri JD. Stimulating Intrinsic Motivation in Millennial Students: A New Generation, a New Approach. ANATOMICAL SCIENCES EDUCATION 2020; 13:250-271. [PMID: 31021529 DOI: 10.1002/ase.1884] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 04/17/2019] [Accepted: 04/21/2019] [Indexed: 06/09/2023]
Abstract
There has been a fundamental change in health care pedagogy to address the demands and challenges posed by the present generation of millennial students. There is also a growing recognition of the role of intrinsic motivation as a catalyst in a positive learning experience. The term intrinsic motivation refers to energizing behavior that comes from within an individual and develops due to an inherent interest in the activity at hand. However, stimulating intrinsic motivation in the present generation of millennial health care students is a daunting task, considering their diverse and disparate nature. In addition, the inherent generational differences between educators and students, and an increasing emphasis on technological tools have resulted in a dichotomy in the educational environment leading to the development of a greater incidence of burnouts among students. Hence, numerous innovative techniques have been introduced in health care education to enhance the levels of intrinsic motivation in these students. Unfortunately, most of these approaches have only been moderately successful due to their limited ability to address the unique educational expectations of millennial students. The cumulative evidence suggests that specific approaches to stimulate intrinsic motivation should aim at nurturing the learning efforts of students, bridging the generational barriers between educators and students, and ameliorating the stress associated with health care education. Hence, the specific aim of this narrative review is to suggest empirically proven curricular strategies and institutional reforms to enhance intrinsic motivation in health care students belonging to the Millennial Generation.
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Affiliation(s)
- Joydeep Dutta Chaudhuri
- School of Occupational Therapy, College of Health Sciences, Husson University, Bangor, Maine
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Tukukino C, Wallerstedt SM. Drug information centre queries and responses about drug interactions over 10 years-A descriptive analysis. Basic Clin Pharmacol Toxicol 2020; 126:65-74. [PMID: 31310705 PMCID: PMC6972620 DOI: 10.1111/bcpt.13294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/08/2019] [Indexed: 01/19/2023]
Abstract
Many people are treated with ≥1 drug, implying that risks of drug interactions need to be considered. The aim of this study was to describe drug interaction queries from healthcare professionals to a drug information centre in Sweden over 10 years focusing on drugs frequently asked about and the advice provided. Advice was recorded in mutually exclusive groups: Avoid, Adjust dose, Separate intake, Vigilance or No problem. For queries with Avoid, Adjust dose or Separate intake advice, alerts were extracted from an interaction database (Janusmed). Of 4335 queries to the centre in 2008-2017, 589 (14%) concerned interactions. Most were posed by physicians (91%) and concerned a specific patient (83%) before treatment initiation (76%). Sertraline, warfarin and methotrexate were the most frequently asked about, whereas queries about cyclophosphamide and rifampicine occurred most often in relation to the number of exposed patients. Advice provided in 557 (95%) replies comprised Avoid: n = 85 (15%), Adjust dose: n = 57 (10%), Separate intake: n = 17 (3%), Vigilance: n = 235 (42%) or No problem: n = 163 (29%). In all, 113 (71%) of 159 queries with Avoid/Adjust dose/Separate intake advice elicited an action alert on Janusmed, whereas 31 (20%) did not result in any alert at all. Summarized, seven in ten replies from the drug information centre recommended an explicit drug treatment action, regarding either specific prescribing aspects, for instance dose adjustments, or active follow-up including monitoring potential adverse reactions and/or laboratory results. Readily accessible decision support regarding drug interactions often provides relevant action alerts, but cannot be solely relied on.
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Affiliation(s)
- Carina Tukukino
- Department of Clinical PharmacologySahlgrenska University HospitalGothenburgSweden
- Department of Pharmacology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Susanna M. Wallerstedt
- Department of Pharmacology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- HTA‐centrumSahlgrenska University HospitalGothenburgSweden
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"It's helpful to get the time and opportunity to discuss drug treatment; that's what I think is the most important thing."-A qualitative study on prescribing education in junior physicians. Eur J Clin Pharmacol 2019; 76:249-255. [PMID: 31758216 DOI: 10.1007/s00228-019-02764-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND As prescribing skills are a prerequisite for rational use of medicines, and education and training are important in acquiring these skills, we aimed to explore what aspects junior physicians find important when being taught the art of prescribing. METHODS Written feedback from 34 interns after participating in an educational session as part of a randomized controlled study at a university hospital formed the qualitative data in this study. Manifest content analysis was performed, guided by the research question "Educating junior physicians in the art of prescribing: what aspects do they find important?" Meaning units were extracted and categorized, and emergent themes were identified. RESULTS Five themes emerged. The first, clinical relevance, was exemplified by the categories valuable for health care; perceived relevance for one's own work; and translating theory into practice while the second, applicable content, included categories such as clinical advice; practical tips on using the electronic medical record system; and tools that facilitate. The third and fourth themes, reality-based teaching and creative discussions, were exemplified by the categories patient cases and feedback; and discussion-based teaching; wide-ranging discussions and a permissive and open atmosphere, respectively. In the last theme, effective structure, we identified the categories clear structure; small group teaching; allocated time for discussion; well-organized administration; and home assignment for practice. CONCLUSION Creative discussions, effectively structured in small group sessions, with clinically relevant, reality-based content built on case studies and feedback, are aspects which junior physicians find important when educated in the art of prescribing.
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Lönnbro J, Nylén K, Wallerstedt SM. Developing professional confidence in the art of prescribing-a randomized controlled study on structured collegial discussions during internship. Eur J Clin Pharmacol 2019; 75:687-696. [PMID: 30693366 DOI: 10.1007/s00228-018-02619-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/21/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate whether an educational intervention based on collegial discussions on patient cases could increase interns' professional confidence in prescribing. METHODS In a randomized controlled study at Sahlgrenska University Hospital, Gothenburg, Sweden, 69 interns (median age: 29 years, 54% female) were allocated to an intervention or control group. The intervention consisted of two 3-h seminars based on collegial discussions of patient cases focused on performing medication reviews. This included reconciling the drug treatment and ascertaining that it is reasonable given the patient's current health status, as well as tips on practical handling of the medical records system and integrated decision support. Self-assessed confidence in performing medication reviews was evaluated with questionnaires distributed at baseline and at 6-month follow-up. RESULTS Fifty-seven (83%) interns completed the questionnaires. Although the opposite was found at baseline, intervention interns, in comparison with controls, at follow-up, were more confident in performing medication reviews (4.3 ± 0.9 vs. 3.6 ± 1.3, P = 0.034; 1 = completely disagree to 5 = completely agree). At follow-up, the intervention participants had increased their confidence in prescribing to a greater extent compared with the control participants, including performing medication reviews as well as taking responsibility for the medication list at discharge: + 1.5/+ 1 vs ± 0 on the 5-point agreement scale (all P ≤ 0.01). Among other positive outcomes, the intervention increased the interns' awareness of adverse effects as a potential cause of symptoms and their confidence in withdrawing a medication. CONCLUSION Structured collegial discussions on pharmacotherapy, even of a relatively short duration, can increase junior physicians' professional confidence in prescribing medicines.
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Affiliation(s)
- Johan Lönnbro
- Department of Medicine, Sahlgrenska University Hospital, 413 46, Gothenburg, Sweden
| | - Karin Nylén
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden. .,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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