Integrating a pharmacist into the perioperative setting.

This paper describes the integration of a pharmacist into a perioperative environment and the ensuing quality and economic benefits. Deficiencies were identified in medication management in operating theatres (OT) at a large tertiary hospital. A perioperative pharmacist was employed for a 6-month pilot period, with permanent funding dependent on demonstration of agreed economic benefits.

Neurotoxicity in chronic lithium poisoning.

Background: Lithium-induced neurotoxicity typically occurs with chronic accumulation rather than following acute overdose. There is little emphasis in the literature on the protracted nature of lithium neurotoxicity long after the lithium concentration returns to the therapeutic range.

Aims: To characterise lithium neurotoxicity, with a view of increasing awareness of this important phenomenon.

Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review.

Prescribing of potentially inappropriate medications (PIMs) that pose more risk than benefit in older patients is a common occurrence across all healthcare settings. Reducing such prescribing has been challenging despite multiple interventions, including educational campaigns, audits and feedback, geriatrician assessment and formulary restrictions. With the increasing uptake of electronic medical records (EMRs) across hospitals, clinics and residential aged care facilities (RACFs), integrated with computerized physician order entry (CPOE) and e-prescribing, opportunities exist for incorporating clinical decision support systems (CDSS) into EMR at the point of care.

Prescribing in the oldest old inpatients: a retrospective analysis of patients referred for specialist geriatric consultation.

Background: While medications may prolong life and prevent morbidity in older people, adverse effects of polypharmacy are increasingly recognised. As patients age and become frail, prescribing may be expected to focus more on symptom control and minimise potentially harmful preventive medication use that confer little benefit within a short lifespan. Whether prescribing practice shifts to one of symptom controls among the oldest old admitted to hospital remains unclear.

Self-poisoning by older Australians: a cohort study.

Objective: To examine the epidemiology and severity of self-poisoning by older people in Australia; to compare these data with those for overdoses in younger adults.

Design, Setting, Participants: A cohort study of people presenting to a tertiary toxicology centre after self-poisoning over 26 years (1987-2012).

Main Outcome Measures: Hospital length of stay (LOS); types of drug ingested; intensive care unit (ICU) admissions; in-hospital deaths.

A medication review and deprescribing method for hospitalised older patients receiving multiple medications.

Background: Prescribing of multiple medications in older patients poses risk of adverse drug events.

Aim: To determine whether a structured approach to deprescribing - identifying and discontinuing unnecessary medications - in the inpatient setting is feasible and reduces medication burden.

Methods: Prospective pilot study of a convenience sample of patients aged ≥65 years admitted acutely to general medicine units in a tertiary hospital and receiving eight or more regular medications on presentation.

A clinical audit of high-cost and off-label drug use in dermatology.

Background/objectives: The use of high-cost, off-label, unsubsidised drugs has become valuable in the management of dermatology patients with challenging conditions unresponsive to conventional therapy. Currently, there is no dedicated funding and a paucity of evidence for such drugs. The aim of this audit was to review outcomes and costs.

Polypharmacy among inpatients aged 70 years or older in Australia.

Objectives: To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy.

Design: Prospective cohort study.

Participants And Setting: Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010.

Adherence to guideline-based antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease in an Australian tertiary hospital.

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are an important cause of acute hospital admissions and incur significant costs, which include antibiotic costs.

Aims: This study aimed to (i) define antibiotic prescribing practice in patients admitted to a tertiary hospital with AECOPD and compare this with current locally and nationally recognised antibiotic prescribing guidelines and (ii) correlate variations in guideline-concordant antibiotic prescribing with mean length of stay (LOS) and rates of unplanned readmission to hospital.

Methods: Retrospective case series of 84 consecutive patients with uncomplicated AECOPD who met pre-specified selection criteria.

Experience with low-dose rituximab in off-label indications at two tertiary hospitals.

Background: Rituximab is a monoclonal antibody directed against B cells and is increasingly used to treat a variety of autoimmune conditions. Most published evidence reporting the successful use of rituximab in off-label indications has empirically used a high-dose regimen (either 375 mg/m(2) weekly for 4 weeks, or 1000 mg × 2), which is the approved course of treatment for lymphoma and rheumatoid arthritis patients.

Aims: The aims of this report are to review the indications, outcomes and adverse events of low-dose (500 mg twice, given 1-2 weeks apart), off-label use of rituximab in our institutions, and to review the available evidence.

Off-label use of recombinant factor VIIa in two tertiary hospitals in Queensland.

Background: Recombinant factor VIIa (rFVIIa) is used for many off-label indications without high quality evidence to support its efficacy. The aim of this study was to determine indications for use of off-label rFVIIa, efficacy and safety, and adherence to institutional guidelines.

Methods: We performed a retrospective review of off-label rFVIIa at two tertiary hospitals from 2007 to 2010.

Deciding when to stop: towards evidence-based deprescribing of drugs in older populations.

Minimising the harm from inappropriate prescribing in older populations is a major urgent concern for modern healthcare systems. In everyday encounters between prescribers and patients, opportunities should be taken to identify patients at high risk of harm from polypharmacy and reappraise their need for specific drugs. Attempts to reconcile life expectancy, comorbidity burden, care goals and patient preferences with the benefits and harms of medications should be made in every patient at significant risk.

Association of pre-transplant statin use with delayed graft function in kidney transplant recipients.

Background: Administration of HMG-CoA reductase inhibitors (statins), prior to ischemia or prior to reperfusion has been shown to decrease ischemia-reperfusion renal injury in animal studies. It is unknown whether this protective effect is applicable to renal transplantation in humans. The aim of this study was to determine the relationship between prior statin use in renal transplant recipients and the subsequent risk of delayed graft function.

Outcomes in patients with gram-negative sepsis treated with gentamicin.

Objective: Recent changes to therapeutic drug monitoring (TDM) of gentamicin have been advocated in Australia. It remains uncertain whether these will have an effect on hard clinical endpoints. The aim of this study was to determine clinical outcomes in patients with gram-negative infections treated with gentamicin.

Severe acute liver injury associated with lumiracoxib.

Background And Aim: Significant elevations in liver transaminases were noted in some patients during pre-marketing clinical trials with lumiracoxib, a selective COX-2 inhibitor. It was withdrawn from the Australian market in August 2007, because of an association with severe liver injury. We describe in detail three cases of severe liver injury in patients taking lumiracoxib

Methods: Three patients admitted to our hospital with severe liver injury and taking lumiracoxib are described in detail, together with information on a further six cases reported to the Australian Therapeutics Goods Administration (TGA), none of whom had pre-existing liver disease or obvious risk factors for liver disease.

Therapeutic drug monitoring of tacrolimus by liquid chromatography-tandem mass spectrometry: is it truly a routine test?

Therapeutic drug monitoring of tacrolimus by high-performance liquid chromatography-tandem mass spectrometry has become standard practice. We report on the long-term (4.5 years) use of one such method.

Use and monitoring of low dose rituximab in myasthenia gravis.

Background: Myasthenia gravis is an autoimmune disorder of the neuromuscular junction. Rituximab (RTX), a monoclonal antibody to CD20, leads to B lymphocyte depletion and has been used in some autoimmune disorders, including small case series of myasthenia gravis patients.

Methods: A retrospective analysis was performed of all patients with acetylcholine receptor (AChR) (11 subjects) or muscle specific kinase antibody (MuSK) positive myasthenia gravis (three subjects), who had been treated with RTX in Brisbane, Australia.

Measurement of urinary oxypurinol by high performance liquid chromatography-tandem mass spectrometry.

Oxypurinol is the active metabolite of allopurinol which is used to treat hyperuricaemia associated with gout. Both oxypurinol and allopurinol inhibit xanthine oxidase which forms uric acid from xanthine and hypoxanthine. Plasma oxypurinol concentrations vary substantially between individuals and the source of this variability remains unclear.

The current role of liquid chromatography-tandem mass spectrometry in therapeutic drug monitoring of immunosuppressant and antiretroviral drugs.

Therapeutic drug monitoring of critical dose immunosuppressant drugs is established clinical practice and there are similar good reasons to monitor antiretrovirals. The aim of this article is to review the recent literature (last five years), with particular reference to the use of liquid chromatography-tandem mass spectrometry (LC-MS/MS). LC-MS/MS offers many potential advantages.

Using N-of-1 trials to improve patient management and save costs.

Background: N-of-1 trials test treatment effectiveness within an individual patient.

Objective: To assess (i) the impact of three different N-of-1 trials on both clinical and economic outcomes over 12 months and (ii) whether the use of N-of-1 trials to target patients' access to high-cost drugs might be cost-effective in Australia.

Design: Descriptive study of management change, persistence, and costs summarizing three N-of-1 trials.

Effects of perhexiline on myocardial deformation in patients with ischaemic left ventricular dysfunction.

Background: Perhexiline improves functional capacity in heart failure, but the mechanisms are undefined. We sought its effects on myocardial deformation in patients with viable myocardium.

Methods: Thirty-six medically-treated patients, stable at least 6 months post-infarction with LV dysfunction and myocardial viability shown by dobutamine echo (DbE) were randomised to receive perhexiline or matching placebo for 1 year.