Safety of opioid patch initiation in Australian residential aged care

Explores opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Abstract Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Design: A cross-sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. Setting: Sixty residential aged care facilities in New South Wales. Participants: Residents receiving an initial opioid patch during the study period Main outcome measure: The proportion of residents who were opioid-naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. Results: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid-naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up-titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. Conclusions: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid-naive in the 4 weeks before initiation. &nbsp

Analysis Of Yscf And Associated Homologs And The Presence Of An Inflammatory Molecular Pattern

Gram-negative pathogen, Yersinia pestis, expresses a type three secretion system to accomplish its virulence. The YscF needle protein provides a conduit of effectors from bacterium to eukaryote and is exposed to the host immune system. This thesis explores YscF and its associated needle homologs and the possibility of recognition as pathogen-associated molecular patterns (PAMP) by macrophage tissue culture. Interestingly, Salmonella homologs PrgI and SsaG are inflammatory suggesting conservation of the inflammatory pattern in the T3SS needle protein

Regulatory withdrawal of medicines marketed with uncertain benefits : the bevacizumab case study

Acknowledgements Professor Elizabeth Roughead is funded by a Future Fellowship from the Australian Research Council. The views expressed are those of the authors, the sponsor had no role in the preparation of the manuscript.Peer reviewedPublisher PD

The Therapeutic Value of the Quartz Mercury Vapour Lamp in the Treatment of Acute Scarlet Fever and Serum Unticaria

A study of a series of unselected cases of scarlet fever has been carried out with the object of demonstrating in this disease the effect of exposure to ultra-violet light upon the course, specific characteristics, and complications. For this purpose observations upon one hundred and eighty seven cases are set out and the relevant positive findings are controlled by parallel series each of similar numbers of cases, (a) which received no specific treatment, and (b) which were treated by antiscarlatinal serum. With the further aim of investigating the effect of irradiation upon the incidence and nature of serum urticaria one hundred cases showing this allergic manifestation were treated by ultra-violet light; the facts emerging from this procedure are controlled by comparison with a further group of one hundred cases not so treated. In the production of urticaria the relative potency of antidiphtheritic and antiscarlatinal sera has been observed in one hundred cases of diphtheria and in one hundred cases of scarlet fever, all of which received in treatment approximately equal volumes of the appropriate antiserum. The possibility of modifying, by preliminary irradiation, the allergic potentiality of serum has been probed in one hundred and ten cases receiving serum thus prepared. The observed facts as set out in the foregoing pages would appear to justify the following conclusions 1. Irradiations from a quartz mercury vapour lamp are entirely without effect on the duration of the rash of scarlet fever. It is to be noted, however, that, when viewed under the lamp, the characteristics of the rash are accentuated and that in this medium they remain visible for an appreciably longer time than when viewed in ordinary white light, and the mercury vapour lamp has thus a definite value as an aid to the diagnosis of doubtful rashes. 2. Despite the fact that the fall of temperature of acute scarlet fever cases is uninfluenced by exposure to ultra-violet light, it is desirable that the initial temperature of the patient be allowed to become normal before exposure to the lamp. (vide infra 5). 3. Although the general well being of the patient is improved the actual duration of the disease is unaffected by exposure to ultra-violet light. 4. Ultra-violet light has little or no effect on the normal course of scarlatinal desquamation. 5. Exposure of scarlet fever patients to ultraviolet irradiations diminishes the tendency to develop septic sores, otorrhoea and rhinitis. The incidence of nephritis is unaltered provided, as in (2), irradiation is commenced after the initial temperature has settled. Other common complications are unaffected. Although it is unwise to draw conclusions from the happy outcome of isolated cases, the rapid cure of a single Instance of erythema nodosum, a condition notoriously refractory to treatment, amply justifies the massive doses utilised and offers a useful suggestion for a routine procedure in this condition. 6. Following the use of antiscarlatinal serum the liability to urticaria is greater than in the case of antidiphtheritic serum, while the developed rash is more irritable and of longer duration. 7. Cutaneous allergy to antis carlatinal serum occurs usually on or about the eighth day, has an average duration of 52.4 hours, is accompanied by itching in 42%, of cases, and by joint pains in 10%. 8. In the treatment of serum urticaria ultraviolet irradiation with the quartz mercury vapour lamp is of undoubted value - itching is promptly relieved, and the duration of the urticaria diminished by an average period of 30.1 hours. The local and systemic effects of the rays are seen to best advantage when dosage is pushed to the production of a second degree erythema only. 9. Preliminary irradiation of the serum produces no difference in the incidence of urticaria, delays its appearance for approximately one day, shortens its duration by 4.6 hours, modifies markedly its irritability and diminishes any associated rise in temperature by 13.9%. Preliminary irradiation of the serum is apparently not inimical to its antitoxic properties and therapeutic value

A Cooperative Strategy for 21st Century Seapower

A Cooperative Strategy for 21st Century Seapower” represents an historical first. Never before have the maritime forces of the United States—the Navy, Marine Corps, and Coast Guard—come together to create a unified maritime strategy. This strategy stresses an approach that integrates seapower with other elements of national power, as well as those of our friends and allies. It describes how seapower will be applied around the world to protect our way of life, as we join with other like-minded nations to protect and sustain the global, inter-connected system through which we prosper

The challenge of pharmaceutical promotion regulation in Malaysia.

Information on medicines provided to doctors should be of high quality to support the quality use of medicines. Pharmaceutical promotion is used by pharmaceutical companies to disseminate information about their medicines to doctors. Although the companies claim that promotion offers evidence-based information, research shows that pharmaceutical promotion often provide bias and poor quality of information that may negatively influence doctors' prescribing behaviour. In Malaysia, the pharmaceutical market is highly competitive. It appears that pharmaceutical companies actively promoting their medicines to Malaysian doctors. Given the absence of a comprehensive independent source of prescribing information in Malaysia, Malaysian doctors may be more likely to rely on medicines information provided by pharmaceutical companies. Clearly, pharmaceutical promotional activities in Malaysia need to be effectively regulated. This article will discuss the regulation of pharmaceutical promotion and current policy challenges in Malaysia

Quality of Pharmaceutical Advertisements in Medical Journals: A Systematic Review

Journal advertising is one of the main sources of medicines information to doctors. Despite the availability of regulations and controls of drug promotion worldwide, information on medicines provided in journal advertising has been criticized in several studies for being of poor quality. However, no attempt has been made to systematically summarise this body of research. We designed this systematic review to assess all studies that have examined the quality of pharmaceutical advertisements for prescription products in medical and pharmacy journals.Studies were identified via searching electronic databases, web library, search engine and reviewing citations (1950 - February 2006). Only articles published in English and examined the quality of information included in pharmaceutical advertisements for prescription products in medical or pharmacy journals were included. For each eligible article, a researcher independently extracted the data on the study methodology and outcomes. The data were then reviewed by a second researcher. Any disagreements were resolved by consensus. The data were analysed descriptively. The final analysis included 24 articles. The studies reviewed advertisements from 26 countries. The number of journals surveyed in each study ranged from four to 24 journals. Several outcome measures were examined including references and claims provided in advertisements, availability of product information, adherence to codes or guidelines and presentation of risk results. The majority of studies employed a convenience-sampling method. Brand name, generic name and indications were usually provided. Journal articles were commonly cited to support pharmaceutical claims. Less than 67% of the claims were supported by a systematic review, a meta-analysis or a randomised control trial. Studies that assessed misleading claims had at least one advertisement with a misleading claim. Two studies found that less than 28% of claims were unambiguous clinical claims. Most advertisements with quantitative information provided risk results as relative risk reduction. Studies were conducted in 26 countries only and then the generalizability of the results is limited.Evidence from this review indicates that low quality of journal advertising is a global issue. As information provided in journal advertising has the potential to change doctors' prescribing behaviour, ongoing efforts to increase education about drug promotion are crucial. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines

Collaborative medication management services: improving patient care

The document attached has been archived with permission from the editor of the Medical Journal of Australia (10 January 2008). An external link to the publisher’s copy is included.Objective: To implement and evaluate a collaborative medication management service model. Design: Participatory action research. Setting and participants: The study was conducted from March 1999 to March 2000; 1000 patients, 63 pharmacists and 129 general practitioners from six Divisions of General Practice in South Australia participated. Interventions: A collaborative service delivery model, involving a preliminary case conference, a home visit and a second case conference, was agreed through discussions with medical and pharmacy organisations and then implemented. Outcome measures: Medication-related problems; actions recommended; actions implemented; and outcomes after actions taken. Results: Overall, 2764 problems were identified. The most common medication-related problem (17.5% of all problems) was the need for additional tests. Thirty-seven per cent of problems related to medicine selection, 20% to patient knowledge, and 17% to the medication regimen. Of 2764 actions recommended to resolve medication-related problems, 42% were implemented. Of the 978 problems for which action was taken and follow-up data were available, 81% were reported to be "resolved", "well managed" or "improving". Conclusion: This implementation model was successful in engaging GPs and pharmacists and in assisting in the resolution of medication-related problems.Andrew L Gilbert, Elizabeth E Roughead, Justin Beilby, Kathy Mott and John D Barrat

Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: a retrospective cohort study

Objectives: To determine chronic opioid use pre-THA (total hip arthroplasty) and post-THA, and risk factors for persistent or new chronic opioid use post-THA. Design: Retrospective cohort study. Setting: Australian Government Department of Veterans' Affairs health claims database. Participants: 9525 patients who had an elective unilateral THA between 1/01/2001 and 12/31/2012. Primary outcome measure: Chronic opioid use. Defined as 90 days of continuous opioid use or 120 days of non-continuous use. Results: Pre-THA, 6.2% (n=593) of patients were chronic users, while 5.2% (n=492) were post-THA. Among the 492 postoperative chronic users, 302 (61%) were chronic users pre-THA and post-THA and 190 (39%) became new chronic users after surgery. Risk factors for persistent chronic use were younger age (OR=0.96, 95% CI 0.93 to 0.99/1-year increment), back pain (OR=1.99, 95% CI 1.20 to 3.23), diabetes (OR=3.52, 95% CI 1.05 to 11.8), hypnotics use (OR=2.52, 95% CI 1.48 to 4.30) and higher pre-THA opioid exposure (compared with opioid use for 94–157 days, 157–224 days (OR=3.75, 95% CI 2.28 to 6.18), 225+ days (OR=5.18, 95% CI 2.92 to 9.19). Risk factors for new chronic opioid use post-THA were being a woman (OR=1.40, 95% CI 1.00 to 1.96), back pain (OR=3.90, 95% CI 2.85 to 5.33), depression (OR=1.70, 95% CI 1.20 to 2.41), gastric acid disease (OR=1.62, 95% CI 1.16 to 2.25), migraine (OR=5.11, 95% CI 1.08 to 24.18), liver disease (OR=4.33, 95% CI 1.08 to 17.35), weight loss (OR=2.60, 95% CI 1.06 to 6.39), dementia (OR=2.19, 95% CI 1.04 to 4.61), hyperlipidaemia (OR=1.38, 95% CI 1.00 to 1.91), hypnotics (OR=1.56, 95% CI 1.13 to 2.16) and antineuropathic pain medication use (OR=3.11, 95% CI 2.05 to 4.72). Conclusions: Patients undergoing THA are exposed to opioids for long periods of time, putting them at high risk of harm related to opioid use. We identified groups at risk of chronic opioid use, including younger patients and women, as well as modifiable risk factors of chronic opioid use, including level of opioid exposure presurgery and hypnotic use. These indicators of chronic opioid use can be used by clinicians to target patient groups for suitable pain management interventions.Maria C S Inacio, Craig Hansen, Nicole L Pratt, Stephen E Graves, Elizabeth E Roughea