Power outages and refrigerated medicines: The need for better guidelines, awareness and planning.

WHAT IS KNOWN AND OBJECTIVE: Vaccines and other pharmaceuticals are essential medical supplies that require continuous storage at specific temperatures to maintain viability. Power outages can lead to a break in the cold chain, resulting in the degradation of essential medicines. COMMENT: After a power outage, the stability of vaccines and other medicines can be difficult to ascertain. Many public health guidelines therefore recommend discarding potentially compromised pharmaceuticals unless the cold chain can be guaranteed-a costly endeavour. There are government guidelines aimed at minimizing exposure to high temperatures in the event of a power outage; however, the usefulness of these guidelines is uncertain. WHAT IS NEW AND CONCLUSION: The actual cost of vaccine and pharmaceutical loss due to a break in the cold chain is poorly studied and requires further research. Additional recommendations regarding the stability of specific medicines would also be a valuable resource.

Feasibility of a real-time hand hygiene notification machine learning system in outpatient clinics.

BACKGROUND: Various technologies have been developed to improve hand hygiene (HH) compliance in inpatient settings; however, little is known about the feasibility of machine learning technology for this purpose in outpatient clinics. AIM: To assess the effectiveness, user experiences, and costs of implementing a real-time HH notification machine learning system in outpatient clinics. METHODS: In our mixed methods study, a multi-disciplinary team co-created an infrared guided sensor system to automatically notify clinicians to perform HH just before first patient contact. Notification technology effects were measured by comparing HH compliance at baseline (without notifications) with real-time auditory notifications that continued till HH was performed (intervention I) or notifications lasting 15 s (intervention II). User experiences were collected during daily briefings and semi-structured interviews. Costs of implementation of the system were calculated and compared to the current observational auditing programme. FINDINGS: Average baseline HH performance before first patient contact was 53.8%. With real-time auditory notifications that continued till HH was performed, overall HH performance increased to 100% (P < 0.001). With auditory notifications of a maximum duration of 15 s, HH performance was 80.4% (P < 0.001). Users emphasized the relevance of real-time notification and contributed to technical feasibility improvements that were implemented in the prototype. Annual running costs for the machine learning system were estimated to be 46% lower than the observational auditing programme. CONCLUSION: Machine learning technology that enables real-time HH notification provides a promising cost-effective approach to both improving and monitoring HH, and deserves further development in outpatient settings.

Stability of dobutamine in continuous ambulatory delivery devices.

WHAT IS KNOWN AND OBJECTIVE: Continuous infusion of dobutamine plays an important role in the management of patients with end-stage heart failure. Home infusion of dobutamine using a continuous ambulatory delivery device (CADD) facilitates the management of patients in their home, avoiding complications associated with long-term hospitalization. However, the stability of dobutamine in CADD is currently unknown. Therefore, this study investigated the physicochemical stability of dobutamine in CADDs at three different temperatures over various time points. METHODS: Six CADDs (three containing dobutamine 10 mg/mL in 0.9% sodium chloride and three containing dobutamine 10 mg/mL in 5% glucose) were prepared and stored at 4°C for 7 days, followed by 12 hours at 35°C and then for another 12 hours at 25°C. An aliquot (n = 3) was withdrawn aseptically at 0, 24, 48, 72, 96, 120, 144 and 168 hours when stored at 4°C, and at 0, 6 and 12 hours when stored at the other two temperatures. Each sample was analysed for dobutamine concentration using a stability-indicating high-performance liquid chromatography. All the samples were also evaluated for change in pH, colour and for particle content. RESULTS AND DISCUSSION: No evidence of particle formation, colour or pH change was observed throughout the study period. Dobutamine, when admixed with 0.9% sodium chloride or 5% glucose, was found to be chemically stable for at least 168 hours at 4°C and for another 12 hours at 35°C and for another 12 hours at 25°C. WHAT IS NEW AND CONCLUSIONS: Our findings will allow health professionals to provide a weekly supply of dobutamine-containing CADDs to patients for home infusions. Continuous infusion over a 24-hour period using one CADD per day will also decrease the number of exchanges required and thus reduce the risk of catheter-related bloodstream infections.

We have had a gutful: The need for deprescribing proton pump inhibitors.

WHAT IS KNOWN AND OBJECTIVE: Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. METHODS: Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. RESULTS AND DISCUSSION: Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications. WHAT IS NEW AND CONCLUSION: Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Impetigo: A need for new therapies in a world of increasing antimicrobial resistance.

WHAT IS KNOWN AND OBJECTIVE: Impetigo is a highly contagious bacterial skin infection and is one of the most common skin infections in children. Antibiotics are the first-line treatment when multiple lesions exist, but with an increasing prevalence of antibiotic-resistant bacteria the successful management of impetigo in the future is an area of concern. COMMENT: Current treatment options that favour the use of oral antibiotic therapy are increasingly problematic. Widespread use of these agents contributes to antimicrobial resistance and has adverse consequences for individuals and communities. There is a need for new topical antimicrobials and antiseptics as an alternative treatment strategy. WHAT IS NEW AND CONCLUSION: To successfully treat impetigo into the future and ensure that therapy does not contribute to bacterial resistance, additional research is required to ascertain the usefulness of alternative agents, including new topical antimicrobials and antiseptics.

Pain intensity and pain self-management strategies following discharge after surgery: An Australian prospective observational study.

WHAT IS KNOWN AND OBJECTIVE: Up to 80% of patients experience acute pain following surgery. This study aimed to improve the current understanding about the strategies individuals use to self-manage pain following discharge after surgery, stratified by pain intensity. METHODS: A prospective observational study conducted at the Royal Hobart Hospital, Australia, between November 2014 and March 2015. Eligible participants were 18 years or older and had undergone surgery requiring an incision. Patients who had undergone surgery related to cancer, childbirth or multitrauma or those with dementia were excluded. Participants were identified through hospital records and mailed a survey within 1 week of discharge. This survey asked about post-discharge pain, management strategies utilized and advice on self-management of pain provided during their inpatient stay. RESULTS: Five hundred surveys were mailed, with 169 (33.8%) being returned. The median age of the respondents was 57 years (range: 18-92 years); 53% were female. The majority (89.3%) of participants recalled receiving information about pain self-management. Analgesic use was reported by 95.4% of participants in the week following discharge. Moderate-severe pain was reported by 80 participants (47.3%); 63.7% and 11.3% of patients reported underuse and overuse of analgesics compared to what was recommended, respectively. WHAT IS NEW AND CONCLUSION: A high proportion of patients underused analgesics despite experiencing moderate-severe pain. Although the vast majority of participants reported receiving advice regarding pain self-management, this did not appear to translate into optimal pain management after discharge. Different approaches to the provision of advice appear to be required.

Scabies-An ancient itch that is still rampant today.

WHAT IS KNOWN AND OBJECTIVE: Scabies is recognized as a neglected tropical disease responsible for a substantial health and economic burden, especially in resource-poor communities around the world. COMMENT: There are relatively few current treatment options for scabies, and they possess important limitations. The treatments are ineffective in preventing relapse, inflammatory skin reactions and associated bacterial skin infections. There are also safety concerns, especially in children and pregnant women. Furthermore, there has been the emergence of resistance among scabies mites to the classical acaricides. WHAT IS NEW AND CONCLUSION: More research needs to be devoted to developing new treatments for scabies.

Does the "script" need a rewrite? Is medication advice in television medical dramas appropriate?

WHAT IS KNOWN AND OBJECTIVE: Television medical dramas depict the healthcare industry and draw considerable interest from the public, while pharmacists play an integral part in providing medication-related advice to the public and other health practitioners in real life. The main objective of this retrospective, observational study was to assess the appropriateness of medication advice given in televised medical dramas and how frequently pharmacists were involved in providing the medication advice. METHODS: Show selection was based on fictional series with a medical drama theme and having the highest viewership. Approximately 100 randomly selected hours of five medical television dramas (House, Grey's Anatomy, Nurse Jackie, Doc Martin and Royal Pains) were assessed for the appropriateness of advice given based on the medication indicated, number of safety checks performed, and the level of adherence to standard clinical guidelines. The appropriateness of medication advice was assessed as appropriate, mostly appropriate, partially appropriate and inappropriate using a piloted, 0-6 point scale. Other parameters recorded included patient demographics, health professionals involved, and the categories of medicines. RESULTS AND DISCUSSIONS: Medications were mentioned on 424 occasions (on average four times per hour), including 239 occasions where medication advice was given. A pharmacist was involved in giving medication advice only 16 times (7%). Using the assessment tool, overall, medication advice was deemed to be appropriate 24% of the time, mostly appropriate 34%, partially appropriate 13% and inappropriate 7%. Although the medication advice given was often for the correct indication and the advice somewhat followed clinical guidelines, it frequently omitted adequate safety checks. Doc Martin had the highest mean appropriateness score, whereas House and Grey's Anatomy had the lowest. WHAT IS NEW AND CONCLUSIONS: Medication was often used for the correct indication in television medical dramas; however, key safety checks were frequently omitted and other medication-related advice, including dose, was less reliable and accurate. Pharmacists were rarely involved in providing medication advice. Viewers should not base medication-related decisions solely on what they see in television medical dramas, and any medication-related advice should be interpreted with extreme caution.

Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.

WHAT IS KNOWN AND OBJECTIVE: Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy. METHODS: This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy. RESULTS AND DISCUSSION: The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments. WHAT IS NEW AND CONCLUSION: Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk.

BACKGROUND: Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

Safety and efficacy of kunzea oil-containing formulations for the management of psoriasis: a randomized, controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Anecdotally, topical kunzea oil has been used to treat various skin conditions, including psoriasis and eczema, with good results. This study compared the clinical efficacy of kunzea oil (20%)-containing formulations in mild to moderate psoriasis. METHODS: A randomized, comparative, double-blind, 8-week study was undertaken. Thirty patients (age range: 25-74 years and mean ± SD: 52·8 ± 13·6 years) with mild to moderate psoriasis (affecting at least 10% of one or more body regions: arms, head, legs and trunk) randomly received ointment and/or scalp lotion containing 20% kunzea oil (test group) or control medications not containing kunzea oil (control group). Formulations in both treatment arms also contained 5% liquor carbonis detergens (LCD) and 3% salicylic acid. The clinical responses to the test and control formulations were evaluated using the Psoriasis Area and Severity Index (PASI). RESULTS AND DISCUSSION: After 8 weeks of treatment, both test and control groups demonstrated a significant (P < 0·05) improvement in PASI scores. Subjects in the test group had a decrease in mean±SD PASI score from 12·7 ± 7·9 to 6·7 ± 7·2, whereas the control group showed a decrease in PASI score from 8·1 ± 4·6 to 3·5 ± 4·7. Comparative efficacy analysis between the test and control groups did not reveal any significant difference (P > 0·05). WHAT IS NEW AND CONCLUSIONS: The inclusion of kunzea oil made no difference to the efficacy of topical formulations containing LCD and salicylic acid for the treatment of psoriasis.

Community-acquired pneumonia: why aren't national antibiotic guidelines followed?

AIMS: Adherence to guidelines for the management of community-acquired pneumonia (CAP) has been shown to improve patients' clinical outcomes. This study aimed to assess adherence to the Australian Therapeutic Guidelines (TG14) for the empirical management of CAP, and explore the potential barriers affecting adherence to these guidelines. METHODS: Medical records were reviewed for all patients who were diagnosed with CAP within 24 h of presentation at the Royal Hobart Hospital, the main teaching hospital in Tasmania, Australia, between July 2010 and March 2011. A survey of emergency department and medical team prescribers was also undertaken to identify potential barriers to adhere with the guidelines. χ(2) and Fisher's exact tests were used to test the significance between categorical data. To compare categorical and scale data, the Mann-Whitney U-test was used. RESULTS: A total of 193 patient records were assessed. The overall adherence to TG14 for the empirical antibiotic management of CAP was 16.1% (3.1%, 20.7% and 25.4% for patients with mild, moderate and severe CAP, respectively). Ceftriaxone was prescribed to 34.4%, 26.8% and 57.4% of patients with mild, moderate and severe CAP, respectively. The response rate to the barrier survey was 43.1%; of those who responded, 46.4% thought the influence of senior doctors on junior doctors could be a factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the existence of other guidelines that conflict with TG14 (28.6%). CONCLUSIONS: Adherence to CAP treatment guidelines was poor, especially in patients with mild disease. Prescribing was mainly influenced by senior doctors. Efforts to improve compliance with CAP treatment guidelines should consider the potential barriers that hinder adherence.

Renal drug dosing recommendations: evaluation of product information for brands of the same drug.

OBJECTIVES: To review the product information (PI) for various brands of the same generic drugs and investigate the extent to which information is currently available on dosing in renal impairment and the concordance between the dosing recommendations for the same generic drug. METHOD: The Monthly Index of Medical Specialities (MIMS) was examined for 28 generic drugs recommended to be used with caution in renal impairment. For each generic drug all available brands listed as having solid oral dosage form were recorded. For each identified brand, the current PI was consulted and data referring to renal impairment was collated. The dissimilarity between these PI regarding the renal dosage recommendation was determined. RESULTS: There was generally a lack of detailed information in the PI on the use of drugs in patients with renal impairment. The majority of PI documents (88 of 155 PI; 57%) provided quantitative dosage recommendations, but this was often not detailed enough to help users to make an informed decision. For 37 PI documents (24%), an altered dosage regimen was proposed without a quantifiable measure of renal function reported in the dose recommendation. The renal function severity category terms used and the associated quantitative values were also not consistent. It was observed that the recommendations varied among different brands of hydromorphone, morphine, oxycodone, tramadol, metformin and topiramate. CONCLUSION: The reporting of renal function quantification methods, and associated dosage recommendations, in PI requires standardisation to ensure optimal drug dosing. Regularly updating of PI is also necessary.

A multifaceted pharmacist intervention to improve antihypertensive adherence: a cluster-randomized, controlled trial (HAPPy trial).

WHAT IS KNOWN AND OBJECTIVES: About half of all patients taking antihypertensives discontinue treatment by 12 months. There is potential for substantial health gains at both individual and population levels through improved treatment adherence. The objective was to evaluate a community pharmacist intervention to improve adherence with antihypertensive medicines with a view to improving blood pressure (BP) control. DESIGN: prospective, non-blinded, cluster-randomized, controlled trial. PARTICIPANTS: adults with primary hypertension who obtained antihypertensives in the previous 6 months. Patients with poor refill adherence were preferentially identified with the help of a purpose-built software application. INTERVENTION: package comprising BP monitor; training on BP self-monitoring; motivational interviewing; medication use review; prescription refill reminders. FOLLOW-UP: six months. PRIMARY OUTCOME: change in proportion self-reporting medication adherence. Secondary outcome: BP changes. RESULTS: Participants (n = 395; intervention - 207; control - 188) had a mean age of 66.7 years; 51.1% were males. The proportion of adherent participants increased in both groups but was not significantly different between groups [57·2% to 63·6% (control) vs. 60·0% to 73·5% (intervention), P = 0·23]. The mean reduction in systolic BP was significantly greater in the intervention group (10·0 mmHg vs. 4·6 mmHg; P = 0·05). The proportion of patients who were non-adherent at baseline and adherent at 6 months was 22·6% (95%CI 5·1-40·0%) higher in the intervention group (61·8% vs. 39·2%, P = 0·007). Among participants with baseline BP above target, reduction of systolic BP was significantly greater in the intervention group [by 7·2 mmHg (95%CI 1·6-12·8 mmHg); (P = 0·01)]. Among participants non-adherent at baseline and above target BP, the proportion reporting adherence at 6 months was significantly greater in the intervention group [56·8% vs. 35·9%, P = 0·039). WHAT IS NEW AND CONCLUSION: This community pharmacist intervention resulted in improved adherence to antihypertensive medication and reduced systolic BP.

Review of computerized clinical decision support in community pharmacy.

WHAT IS KNOWN AND OBJECTIVE: Clinical decision support software (CDSS) has been increasingly implemented to assist improved prescribing practice. Reviews and studies report generally positive results regarding prescribing changes and, to a lesser extent, patient outcomes. Little information is available, however, concerning the use of CDSS in community pharmacy practice. Given the apparent paucity of publications examining this topic, we conducted a review to determine whether CDSS in community pharmacy practice can improve medication use and patient outcomes. METHODS: A literature search of articles on CDSS relevant to community pharmacy and published between 1 January 2005 and 21 October 2013 was undertaken. Articles were included if the healthcare setting was community pharmacy and the article indicated that pharmacy use of CDSS was part of the study intervention. RESULTS AND DISCUSSION: Eight studies were found which assessed counselling, selected drug interactions, inappropriate prescribing and under-prescribing. One study was halted due to insufficient data collection. Six studies showed statistically significant improvements in the measured outcomes: increased patient counselling, 31% reduced frequency of drug-drug interactions (DDIs), reduced frequency of inappropriate medications in the elderly (2·2-1·8% patients) and in pregnant women (5·5-2·9% patients), and increased pharmacists' interventions for under-prescribed low-dose aspirin (1·74 vs. 0·91 per 100 patients with type 2 diabetes) and over-prescribed high-dose proton-pump inhibitors (PPIs) (1·67 vs. 0·17 interventions per 100 high-dose PPI prescriptions). WHAT IS NEW AND CONCLUSION: Most studies showed improved prescribing practice, via direct communication between pharmacists and doctors or indirectly via patient education. Factors limiting the impact of improved prescribing included alert fatigue and clinical inertia. No study investigated patient outcomes and little investigation had been undertaken on how CDSS could be best implemented. Few studies have been undertaken in community pharmacy practice, and based on the positive findings reported, further research should be directed in this area, including investigation of patient outcomes.

Metformin usage in type 2 diabetes mellitus: are safety guidelines adhered to?

AIM: To (i) evaluate the prescribing patterns of metformin in patients with type 2 diabetes mellitus (T2DM) and determine the prevalence of contraindications to its use, especially renal impairment, and (ii) identify potential cases of lactic acidosis (LA) related to metformin usage. METHOD: This retrospective study reviewed all patients with a diagnosis of T2DM and taking metformin who was admitted to a major teaching hospital over an 8-month period. Data including demographics, medical conditions, medications at admission and discharge, and relevant pathology results were extracted from medical records. RESULTS: A total of 301 patients (209 medical patients, 92 surgical patients) taking metformin were included. According to guidelines, approximately 31% and 21% of patients received metformin inappropriately (in the presence of contraindications or in excessive dosage) at admission and discharge, respectively. At admission, 65 patients (n = 301, 21.6%) on metformin had at least one contraindication to its use, and 42 patients (n = 254, 16.5%) were prescribed an excessive dosage according to their renal function. At discharge, 43 patients (n = 301, 14.3%) continued on metformin with at least one contraindication and 21 patients (n = 191, 11%) received an excessive dosage according to their renal function. Four patients had evidence of LA (plasma lactate concentration > 5.0 mmol/L and pH < 7.35) without clinical diagnosis. CONCLUSION: Metformin was often used in patients with contraindications to its use, or in higher than recommended dosages. Reconsideration of the official prescribing information for metformin may be warranted as the risk of harm appears to be very low.

Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources?

BACKGROUND: It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error. AIMS: To determine the concordance among five drug information sources regarding the dosing recommendations provided for drugs considered problematic in patients with renal impairment and to determine the consistency among the sources regarding the definition of renal impairment and categorisation of chronic kidney disease. METHODS: Five standard drug information sources were reviewed for 61 drugs recommended to be used with caution in renal impairment. Information on recommendations for dosage adjustment in renal impairment was extracted and analysed. Further, the definition and classification of renal impairment were recorded. The recommendation for each drug was coded into six different categories and the intersource reliability was calculated. RESULTS: Only slight agreement was observed among the sources (Fleiss Kappa: 0.3). Qualitative data were not well defined, and there was a lack of consistency in quantitative values. Some drugs marked as contraindicated in one source were not mentioned as such in others. Also, drugs considered as not requiring dosage adjustment in one source had explicit recommendations in other sources. The definition and classification of renal impairment differed among the five information sources. CONCLUSIONS: There should be an evidence-based approach to drug dosage adjustment in order to bring uniformity to the recommendations. Regular updating of the content of the drug information sources is also important.

Thromboprophylaxis following hip and knee arthroplasty.

AIM: To determine local thromboprophylaxis prescribing practices following arthroplasty. METHODS: A retrospective review was performed of 300 consecutive hip and knee arthroplasty patients (150 each) over a 2-year period at Tasmania's major public hospital. The provision of thromboprophylaxis, the presence of bleeding/thrombotic risk factors and the prevalence of symptomatic venous thromboembolism (VTE) and major bleeding occurring within 90 days postoperatively were documented. RESULTS: The mean age of the 300 patients (169 females, 131 males) was 68.7 years (standard deviation 10.4). Only 11.3% of knee arthroplasty and 16.7% of hip arthroplasty inpatients had mechanical thromboprophylaxis documented during their stay. All inpatients received pharmacological thromboprophylaxis, predominantly injectable anticoagulants (98.4%). Only 36.5% continued to receive pharmacological thromboprophylaxis following discharge, predominantly an antiplatelet agent (55.5%). The 90-day incidence of symptomatic VTE was 2.7% (95% confidence interval: 1.0-5.0%); 4.0% (95% confidence interval: 1.0-8.0%) for knees and 1.3% (95% confidence interval: 0-5.0%) for hips. The in-hospital and post-discharge VTE incidence was 0.7% and 2.0% respectively. All readmissions for VTE occurred within 1 month of surgery. CONCLUSIONS: While inpatient thromboprophylaxis was routine, it generally was not continued on discharge, potentially leaving many patients exposed to a higher risk of VTE. Most cases of symptomatic VTE occurred after discharge, with the majority requiring readmission to hospital under medical units.Within the limitations of a retrospective study, these findings suggest a need for further research and discussion regarding what constitutes appropriate thromboprophylaxis (type, agent and duration) following hip or knee arthroplasty.

Drug-induced liver injury in the Australian setting.

WHAT IS KNOWN AND OBJECTIVE: The causes of drug-induced liver injury vary worldwide, with limited data regarding drug-induced hepatotoxicity in Australia. This study sought to provide information about the incidence, causes and clinical manifestations of drug-induced hepatotoxicity. METHODS: A retrospective study was performed on all adult inpatients with abnormal liver function tests, defined as an increase of more than twice the upper limit of the normal range in either serum alanine aminotransferase or alkaline phosphatase, over a 12-month period at the major hospital in Tasmania, Australia. A random sample of individual medical records was reviewed and clinical data extracted. The causality of suspected drug-induced liver injury cases was assessed using the Roussel Uclaf Causality Assessment Method. RESULTS: A total of 264 cases were included. Drug-induced liver injury with at least a possible causal relationship was found in 24 cases (9·1%). The mean age at presentation in the 17 patients with possible or probable hepatotoxicity not related to paracetamol or cancer chemotherapy was 60 ± 20·0 years, and 9 (53%) were men. The frequencies of cholestatic, hepatocellular and mixed patterns of liver damage were 9 (53%), 2 (12%) and 6 (35%) respectively. The most common cause was antibiotics (11 of 17; 65%), while flucloxacillin (4 of 17; 24%) was the single agent most often implicated. WHAT IS NEW AND CONCLUSION: Nearly 10% of cases of abnormal liver function could be associated with adverse effects of drugs. The possibility of drug-induced liver injury should always be considered when there is an absence of other apparent hepatic disease.