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A comprehensive model designed to address the issues pertaining to the recruitment, retention and training of the pharmacy workforce in the Gippsland region ...
LETTERS TO THE EDITOR Pharmacy practice in rural Gippsland To the Editor, In order to deliver services across wide geographical areas in rural and remote areas, pharmacists require a thorough knowledge of their community and resources. The Gippsland region consists of six local government areas: Bass Coast, South Gippsland, Baw Baw, Latrobe City, Wellington and East Gippsland, and covers an area of 41 538 km2, stretching from Westernport Bay and the outer eastern suburbs of Melbourne to the New South Wales border. 1 Gippsland’s population in 2006 was 248 424 and is forecast to grow to 260 000 by 2021.1 A steady decline in the population of young adults aged 25 to 35 years is counteracted by an increase in the population of those aged over 55 years. Gippsland’s population is 4.9% of the population of Victoria and the distribution is variable – 30% living in Latrobe City in the towns of Moe, Morwell, Traralgon and Churchill. Health professionals in the region provide a broad range of diagnostic and therapeutic services in the public and private health systems. Identifying workforce shortages is a complex and difficult task not only because of the lack of reliable data but also because of the difficulty of establishing the real health care demand. Smith et al. described the rural allied health workforce in Northern New South Wales and when compared with previous studies, highlighted the need for further research into the strategies for the recruitment and retention of new rural graduates.2 According to the Australian Institute of Health and Welfare, there is a significant decline in full-time equivalent pharmacists per 100 000 population from 70 in small rural centres to 51 in other rural areas and 52 in remote centres.3,4 These figures indicate that there is a critical need for pharmacists in rural and remote areas. To attract and retain pharmacists in these areas, a variety of strategies could be used, such as satellite broadcast lectures, networking, exchange of information and knowledge with pharmacists in metropolitan areas, up-skilling, support of other health professionals, increasing the number of training places in rural and remote areas and family-friendly and flexible work places. Furthermore, adequate incentives are crucial to recruit and retain young pharmacists to rural areas. Future investigations into the number of pharmacists working in the Gippsland region and the pharmacy services offered will allow a better picture of the effectiveness of services provided and the region’s requirements. Moreover, an awareness of the impact of the ageing of the existing pharmacy workforce and the provision of future services is crucial. The following points are essential to understand the region’s supply and demand of pharmacists: workforce demographics, services provided by hospital and community pharmacies, recruitment and retention, and the training needs of pharmacists who continue to practise in rural and remote Gippsland. A comprehensive model designed to address the issues pertaining to the recruitment, retention and training of the pharmacy workforce in the Gippsland region is needed. Maintaining a stable network of pharmacists in

rural and remote areas is important for the health and well-being of Australians. Dr Hanan Khalil, BPharm, PhD Senior Lecturer/Pharmacist Academic Department of Rural and Indigenous Health School of Rural Health Faculty of Medicine, Nursing and Heath Sciences Monash University Moe Vic. 3825 E-mail: [email protected] References 1. Australian Bureau of Statistics. Census 2006. National regional profile. Canberra: Australian Bureau of Statistics; 2006. 2. Smith T, Cooper R, Brown L, Hemmings R, Greaves J. A profile of the rural allied health workforce in northern New South Wales. Aust J Rural Health 2008; 16: 156-63. 3. Australia Institute of Health and Welfare. Australia’s’s health 2006. Canberra: Australia Institute of Health and Welfare; 2006. Available from . Accessed 8 February 2009. 4. Services for Australian Rural and Remote Allied Health. National allied health workforce report. Canberra: Services for Australian Rural and Remote Allied Health; 2004. Available from . Accessed 8 February 2009.

SHPA continuing professional development program To the Editor, Each year Australian pharmacists must renew their registration with the relevant authority. A designated level of continuing education and continuing professional development (CPD) activities must be undertaken for pharmacists to seek re-registration in some states. The Society of Hospital Pharmacists of Australia (SHPA) offers members continuous professional development programs to support lifelong learning and to assist them meet their re-registration criteria. In the 2008 SHPA member survey, five of the top six services offered by SHPA related to education and professional development. The revamp of the SHPA CPD program in 2007 articulated three levels of activities: • Group 1: information delivery without assessment, e.g. conferences, journal articles; • Group 2: information delivery with assessment, e.g. self-assessment questions, exams; and • Group 3: towards facilitating change, e.g. publishing article in a peer-reviewed journal. In late 2007, SHPA hosted a workshop to identify better ways of supporting members’ professional development needs. Discussion highlighted that while members had access to a wide range of Groups 1 and 3 CPD activities there was a dearth of Group 2 activities. A major challenge was offering professional development activities to members who struggle to attend face-toface meetings. Members can access an adequate amount of education services via continuing education (CE) on CD; the Journal of Pharmacy Practice and Research; and articles in the Australian Journal of Pharmacy. Developing online multiple-choice questions (e-MCQs) is a ‘value add’ to these education services, i.e. without leaving their homes, members have access to a range of CE activities.

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In April 2008, the first set of e-MCQs relating to the Geriatric Therapeutics’ article in the March 2008 issue of the Journal of Pharmacy Practice and Research was posted on the SHPA web site and advertised to members. By November 2009, more than 100 sets of e-MCQs had been listed on the web site and over 2400 sets of e-MCQs had been completed by members or event attendees. E-MCQs are accredited as Group 2 activities and questions are available online for 12 months allowing participants the opportunity to complete the questions at a time suitable to them. Choice and Scope of Content The choice of content is driven by its relevance to members, access and accreditation requirements. The articles in the Journal of Pharmacy Practice and Research are chosen using the following criteria: • broad appeal; • topics not covered by other professional development activities; and • sufficient content to support two to three learning objectives and five questions. In principle, multiple-choice questions are developed for most presentations on each CE on CD. Presentations given at SHPA symposia that are recorded for inclusion in CE on CD are automatically considered for e-MCQs. In some instances, event coordinators may wish to offer e-MCQs for attendees enabling conversion of some of the attendance hours from Group 1 to Group 2 activity. In 2009, multiple-choice questions were offered for the SHPA Introductory Oncology Seminar and the NSW Branch Autumn 2009 Symposium. All of the CE articles produced by SHPA for the Australian Journal of Pharmacy are written with e-MCQs. Uptake of e-MCQs In 2008, seven articles from the Journal of Pharmacy Practice and Research had multiple-choice questions developed; 7% of the e-MCQs listed so far. Responses to these seven sets of e-MCQs were analysed to gain insight into the uptake of the e-MCQs concept by SHPA members. Analysis demonstrated that: • questions are answered throughout the 12-month period they are listed on the web site; • 585 sets of e-MCQs have been completed to date (three remain active on the web site); and • 246 members (11%) supplied answers to at least one set of questions (average 2.4 sets of questions and median 2 sets of questions per member); and • 16 members answered all seven sets of questions. The formation of a national registering authority will lead to new national mandatory CPD requirements for Australian pharmacists. This will increase the demand for CPD activities, particularly for pharmacists in regions introducing mandatory professional development. SHPA will ensure conformity with the national CPD program and continue to work on improving access and expanding the scope of topics covered. Karen O’Leary, BPharm Projects Manager Society of Hospital Pharmacists of Australia PO Box 1774 Collingwood Vic. 3066 E-mail: [email protected]

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Pharmacogenomics and pharmacovigilance for better patient outcomes To the Editor, I attended the International Pharmaceutical Federation’s 69th World Congress of Pharmacy and Pharmaceutical Sciences in Istanbul, Turkey from 3 to 8 September 2009. The theme of the meeting was ‘Responsibility for patient outcomes – are you ready?’ Discussions on the potentials and challenges of pharmacogenomics and pharmacovigilance and how they can contribute to improving patient outcomes were highlights. Pharmacogenomics Patient outcomes can be optimised by tailoring pharmacotherapy through a combination of therapeutic drug monitoring, biochemical tests and genetic testing. According to the US National Center for Biotechnology Information, pharmacogenetics refers to the research of inherited genetic differences (variations) in drug metabolism and response. Pharmacogenomics is the general study of all of the different genes that determine drug behaviour. Pharmacogenomics has the potential to predict metabolic phenotypes, risks for adverse effects and likelihood of drug response for individual patients. Therefore, enabling safe, rational and cost-effective prescribing of pharmacotherapy. For example, abacavir’s product information recommends that patients should be screened for the HLA-B*5701 allele before starting treatment. The rationale is that evidence indicates HLAB*5701 is a predictive biomarker for hypersensitivity reactions associated with abacavir.1 McKinnon et al. provide a useful overview of the challenges of implementing pharmacogenomics into routine practice.2 Pharmacovigilance When a new drug is approved for marketing, there are often uncertainties about its long-term safety and efficacy. Thus, it is critical to evaluate a medicine’s dynamic riskbenefit profile over its life cycle. Prompted by recent safety-related withdrawals, there has been considerable impetus worldwide to improve the system of drug development and approval, drug safety surveillance, research and regulatory action post-marketing. The Therapeutic Goods Administration has announced changes including strengthening pharmacovigilance.3 The US Food and Drug Administration launched the Sentinel Initiative in 2008 to establish and implement the Sentinel Network, an integrated, electronic system for monitoring medical product safety to complement existing systems of spontaneous reporting.4 Importantly, the success of pharmacovigilance depends heavily on the cooperation of all health professionals, patients and pharmaceutical companies, particularly with respect to active reporting of risks. Health professionals need to be abreast of drug profiles to ensure patient safety and inform patients about the benefits and risks of medicines. There is a clear benefit for educating pharmacy students and pharmacists about evolving disciplines such as pharmacogenomics and pharmacovigilance. Dr Christine Y Lu, BPharm, MSc, PhD Research Fellow School of Pharmacy and Medical Sciences Sansom Institute University of South Australia

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Adelaide SA 5001 E-mail: [email protected] References 1. Mallal S, Phillips E, Carosi G, Molina JM, Workman C, Tomazic J, et al. HLAB*5701 screening for hypersensitivity to abacavir. N Engl J Med 2008; 358: 568-79. 2. McKinnon RA, Ward MB, Sorich MJ. A critical analysis of barriers to the clinical implementation of pharmacogenomics. Ther Clin Risk Manag 2007; 3: 751-9. 3. Ronaldson KJ. The new age of pharmacovigilance. Med J Aust 2009; 191: 132-4. 4. Platt R, Wilson M, Chan KA, Benner JS, Marchibroda J, McClellan M. The new sentinel network-improving the evidence of medical-product safety. N Engl J Med 2009; 361: 645-7.

Status of generic medicine use in Malaysia To the Editor, The economic downturn has had a negative impact on most sectors around the globe, including health. The burgeoning cost of health is a matter of grave concern for consumers. An important component of these costs is the price of medicines and studies have reported that the price of medicines in Malaysia are high.1 To reduce the cost of medicines, a mechanism widely mandated is substituting innovator medicines with generic medicines. Generic medicines are less expensive because manufacturers do not incur the costs associated with the research and development of innovator medicines. A study at the Universiti Sains Malaysia reported that the use of generic medicines for some drug classes could save patients up to 90% of their total drug costs. 2 Since generic medicines contain well-known ingredients, preclinical tests and clinical trials can be replaced by bioequivalence studies. A tight registration process is a must for innovator and generic medicines and regulatory authorities have a major role in ensuring that the medicines undergo stringent pre-marketing testing on safety and efficacy. Despite the advantages of generic medicines, their use worldwide is lacking.3 There are several barriers to generic medicine use, which can be categorised into three levels: international, health professional and consumer. At an international level, the free trade agreement has posed a major barrier whereby drug patents have been extended beyond their existing date, limiting access data for regulatory processing of generic medicine, and increasing the risk of litigation for countries that issue compulsory licenses.4 These could limit and inhibit the growth of the local generic medicines industry. The most challenging barriers for the use of generic medicines could actually be from the lack of awareness and the negative perceptions towards them among consumers, prescribers and dispensers.5 Most consumers and some prescribers believed that generic medicines are of low quality, which they equated with counterfeit medicines. This will have a negative impact on quality use of medicines among consumers as health professionals play a major role in educating consumers on effective use of medicines. In the present economic climate, consumers need to be informed about the availability of generic medicines and health professionals and government agencies need to educate and promote the uptake of generic medicines among Malaysian consumers and health providers.

Dr Mohamed Azmi Hassali, BPharm(Hon), MPharm (Clin Pharm), PhD Senior Lecturer E-mail: [email protected] Dr Asrul Akmal Shafie, BPharm(Hon), PgDipHealthEcon, PhD Lecturer Discipline of Social and Administrative Pharmacy School of Pharmaceutical Sciences Universiti Sains Malaysia Penang, Malaysia References 1. Chee HL, Barraclough S, editors. Health care in Malaysia: the dynamics of provision, financing and access. Oxon: Routledge; 2007. 2. Shafie AA, Hassali MA. Price comparison between innovator and generic medicines sold by community pharmacies in the state of Penang, Malaysia. J Generic Med 2008; 6: 35-42. 3. Kirking DM, Ascione FJ. Perspectives on generic pharmaceuticals: some conclusions. J Am Pharm Assoc (Wash) 2001; 41: 826-8. 4. Smith RD, Chanda R, Tangcharoensathien V. Trade in health-related services. Lancet 2009; 373: 593-601. 5. Hassali MA, Kong DC, Stewart K. Generic medicines perceptions of general practitioners in Melbourne, Australia. J Generic Med 2006; 3: 214-25.

Pharmacovigilance sessions for undergraduate pharmacy students in Malaysia To the Editor, Pharmacovigilance relates to the detection, assessment, understanding and prevention of drug-related problems.1 Pharmacists can play a vital role in pharmacovigilance programs.2 Since 1989, Malaysia has had a National Pharmacovigilance Program. This program has limited coverage and under-reporting of adverse drug reactions is an important limitation.3 To strengthen this program, there is a need to engage more health professionals, especially pharmacists. A strategy to engage pharmacists would be to sensitise them while they are students. Pharmacoepidemiology is an elective for final year BPharm students at the Universiti Sains Malaysia. The Discipline of Social and Administrative Pharmacy, Universiti Sains Malaysia is committed to promoting rational use of medicines and pharmacovigilance is a priority area of research.4 Associates of the Discipline of Social and Administrative Pharmacy have been successful in implementing pharmacovigilance in Nepal.5 In 2009, the pharmacoepidemiology elective for the final year BPharm students, introduced a session on pharmacovigilance. The session included presentations on theoretical aspects of pharmacovigilance, pharmacovigilance experiences in Nepal and current pharmacovigilance program in Malaysia. On completing the session, student feedback was obtained using a revised five point Likert-scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree).6 The completed questionnaires were analysed using Excel. The Statistical Package for the Social Sciences (version 15) was used for statistical analysis. The Mann Whitney-U test was used to compare the median total scores among male and female students. A p value of < 0.05 was statistically significant.

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Thirty-seven (n = 41) students (males 14, 37%; females 23, 63%) provided feedback. The median score for the students was 79 (IQR 76–82); maximum possible score was 100. The median score for males was 78 (IQR 73–81) and females 79 (IQR 78–83). There was no statistically significant association between the median score and gender (p = 0.3). Overall, the students had a positive opinion and were keen to participate in future sessions (Table 1). Table 1. Responses to the statements in the questionnaire Statement

Median score (range)

Sessions made me aware of pharmacovigilance.

4 (4-5)

Pharmacovigilance is essential to developing countries like Malaysia.

4 (4-5)

ADRs are a major cause of death worldwide.

4 (4-5)

Herbals also carry equal risk of causing ADRs.

4 (3-4)

Pharmacovigilance program in Malaysia is successful.

3 (3-3)

Pharmacy curriculum in Malaysia has adequate content related to 'safe use of medicines'.

4 (3-4)

Are pharmacists allied health professionals?

ADR reporting should be compulsory in Malaysia.

5 (4-5)

Pharmacovigilance should be incorporated in the pharmacy curriculum.

4 (4-5)

Pharmaceutical industry should report ADRs.

5 (4-5)

Pharmacovigilance programs can support the drug regulatory authorities of the country.

4 (4-4)

Session may be useful for me in my future career.

4 (4-5)

Hospital drug and therapeutics committee should be a part of the pharmacovigilance program.

4 (4-4)

Causality assessment is important in pharmacovigilance

4 (3-4)

Severity assessment is not important in pharmacovigilance.*

4 (4-5)

Many ADRs can be prevented if appropriate measures are taken.

4 (4-5)

Patients should not be allowed to report ADRs.*

5 (4-5)

Dose adjustment is a important to prevent ADRs.

4 (3-4)

The session was informative and interesting.

4 (4-4)

I would like to pursue my career in pharmacovigilance/pharmacoepidemiology.

3 (3-3)

I would welcome similar sessions in the future.

4 (3-4)

*Questions were negative and hence the scores were reversed.

Training pharmacy students in developing countries can be useful in consolidating their pharmacovigilance programs. Our experiences might be useful to educators in developing countries. Subish Palaian, MPharm(Clin Pharm) Student E-mail: [email protected] Arjun Poudel, BPharm Student Professor Mohamed IM Ibrahim, PhD Deputy Dean Discipline of Social and Administrative Pharmacy School of Pharmaceutical Sciences Universiti Sains Malaysia Penang, Malaysia

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References 1. World Health Organization. The importance of pharmacovigilance. Geneva: World Health Organization; 2002. 2. van Grootheest AC, de Jong-van den Berg LT. The role of hospital and community pharmacists in pharmacovigilance. Res Social Adm Pharm 2005; 1: 126-33. 3. Aziz Z, Siang TC, Badarudin NS. Reporting of adverse drug reactions: predictors of under-reporting in Malaysia. Pharmacoepidemiol Drug Saf 2007; 16: 223-8. 4. Al-Haddad M, Ibrahim MI. The development of the Discipline of Social and Administrative Pharmacy at University Sains Malaysia. Southern Med Rev 2008; 1: 3-5. 5. Palaian S, Izham M, Mishra P. Monitoring adverse drug reactions using the community pharmacists: a preliminary study from Nepal. Drug Saf 2008; 31: 885-960. 6. Subish P, Khanal S, Alam K, Paudel A. Introducing pharmacovigilance to post graduate pharmacy students in Nepal. Am J Pharm Educ 2009; 73: 114.

To the Editor, Hospital pharmacy, from a health workforce perspective, is grouped with other non-medical, non-nursing allied health professions. This group comprises: audiologists, chiropractors, dietitians, exercise physiologists, occupational therapists, orthoptists, orthotists, pharmacists, physiotherapists, podiatrists, prosthetists, psychologists, radiation therapists, radiographers, social workers, sonographers and speech pathologists. Pharmacists make up around 13% of the health workforce and hospital pharmacy accounts for a small proportion.1 This group, with the exception of physiotherapists, is represented at a national level by their peak body – Allied Health Professions Australia. I sit on this group’s board as a Director on behalf of the Society of Hospital Pharmacists of Australia. The benefits of membership include: • networking and sharing information with member organisations; • collaborative approach to national issues; • national voice on lobbying issues; and • promotion (contact details of member organisations, Commonwealth departments and national organisations are provided). I attended the 8th National Allied Health conference with the theme ‘Allied health leading change’ in Canberra from 25 to 27 October 2009. There was a fair representation of pharmacists who presented at the conference on topics ranging from competency assessment of clinical pharmacists to workload data and clinical roles in chronic disease management. Hospital pharmacists have had a tenuous relationship with their allied health colleagues. Although hospital pharmacists operate in a different manner and have enormous financial responsibilities, we need to seek partnerships with our allied health colleagues. Alliances are different to managerial arrangements. If we want our voices to be heard then we must engage with our allies and speak up.2 Clinically, we are expanding our relationships with dietitians and speech pathologists in elderly patients with swallowing difficulties because as well as foods these patients have to take their medications through nasogastric and PEG tubes. Medication safety issues surrounding the crushing of sustained-release and enteric-coated formulations have led to patient harm.

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In my clinical practice, I share my expertise in chronic pain management with colleagues in occupational therapy, physiotherapy and psychology. Although medication use is pervasive throughout the health system, pharmacy is often dismissed by allied health colleagues and we are not invited to work with them on issues of mutual interest. The reasons are complex and probably related to our different clinical governance models and troglodyte isolationist tendencies. As we continue to evolve with the changes suggested by the National Health Workforce Taskforce, we will be required to work in a more collaborative manner. Otherwise we risk being sidelined and ignored or aggregated with our fellow pharmacists in community unless we actively engage with other allied health professions. Tony Hall, BPharm(Hon), AdvDipClinPharm Teaching, DipMedSci (Palliative Care) Federal Councillor Society of Hospital Pharmacists of Australia, and Senior Lecturer School of Pharmacy Griffith University Gold Coast Qld 4222 E-mail: [email protected] References 1. Australian Health Ministers’ Conference. National health workforce strategic framework. Sydney: Australian Health Ministers’ Conference; 2004. Available from . 2. Allinson YA. Leading change with allied health. Aust J Pharm 2009; 90: 22.

Pharmacist prescribing in the pre-operative setting To the Editor, I have been involved in research looking at the implementation of pharmacist prescribing in the perioperative service at John Hunter Hospital in Newcastle. Inspired by this, I wanted to experience pharmacist prescribing in the UK. I organised a preceptorship with Rekha Shah, Lead Pharmacist for Surgery, Watford General Hospital, West Hertfordshire NHS Trust in their pre-operative assessment clinic. Watford General Hospital has an established preoperative assessment service and pharmacists have been working at these clinics since 1995. A number of pharmacists work in the clinic, ensuring the majority of elective surgery patients are seen by a pharmacist prior to their surgery. Pharmacist prescribing has the potential to fit in well with the current models of care in Australia. Interestingly, some of the barriers that we had encountered at John Hunter Hospital were also issues in the UK. The prescribing pharmacist is able to make decisions about what medicines to stop pre-surgery and when to restart medicines postoperatively discussing and explaining this to the patient. This is not clear cut with all medicines, especially when protocols are not consistent across all surgeons or groups of surgeons for the same type of surgery. Other considerations by the pharmacist, include undertaking a risk assessment to determine the thromboprophylaxis, charting antibiotic prophylaxis, pain relief and postoperative nausea and vomiting prophylaxis.

During the clinic, the pharmacist prescribes all the patients regular medication on the inpatient chart, highlighting medicines that are to be stopped prior to and after surgery, thromboprophylaxis and antibiotic prophylaxis may also be charted. If there are concerns these can be discussed and decisions clarified with the anaesthetist. Not all pharmacists within the service are prescribers, making it difficult to provide a consistent service. For medications with not a lot of evidence or information to guide prescribing pre-operatively there are challenges in developing protocols that can be easily used. Difficulty can also arise when the prescribing pharmacist is not aware of the type of anaesthesia that will be used for a certain patient and type of surgery. This limits the pharmacist’s ability to identify interactions between medications and anaesthetics, but also thromboprophylaxis choice may change depending on whether regional or general anaesthesia is chosen. The time from patients pre-admission clinic appointment until surgery can be anywhere from a couple of days to 18 weeks, with the potential that medication changes may occur after the pre-admission clinic appointment. Many of these barriers in the pre-operative assessment clinic are being worked through, and there is much we can learn from the UK experience. I would like to thank Rekha Shah, the pharmacists and pre-operative assessment clinic staff at Watford General Hospital for sharing their time and experience. I would also like to thank SHPA and DBL for their support. Sally B Marotti, BPharm, GradDipClinPharm, CGP, FSHP Clinical Team Leader The Queen Elizabeth Hospital Woodville South SA 5011 E-mail: [email protected]

Comprehensive Approaches to Improving Minds and Lives To the Editor, The College of Psychiatric and Neurologic Pharmacists’ annual meeting is an international conference that attracts around 400 attendees. The 12th annual meeting was held in Jacksonville, Florida from 19 to 22 April 2009. The four day program included presentations, industry symposia, scientific poster sessions and networking opportunities. Topics presented were wide-ranging and included: management of depression in post-stroke patients; diagnosis and treatment of fibromyalgia; improving adherence in schizophrenia; and a debate on the US and European treatment guidelines for bipolar disorder. Keynote address One of the highlights of the program was the inspiring keynote address by Dr Elyn Saks, Associate Dean and Orrin B Evans, Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California. Dr Saks specialises in mental health law and her research has focused on ethical dimensions of psychiatric research and forced treatment of the mentally ill. Having recently published her memoir,

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The Center Cannot Hold: My Journey Through Madness, about her experience with schizophrenia and acute psychosis, her moving address told a remarkable story and included readings from her book.1 Smoking cessation The pre-meeting workshop on basic tobacco intervention skills training provided an opportunity to discuss complex case studies with other pharmacists working in psychiatry. Clients with mental illness have two to three times the rates of nicotine dependence than the general population. In the US, psychiatric patients represent 44% of the tobacco market, consume 34% of all cigarettes smoked and spend up to 40% of their income on cigarettes. As nicotine-dependent psychiatric patients have increased mortality from cardiovascular and respiratory disorders, lung cancer, infection and diabetes, and have a 20% shorter life span, it is vital to address nicotine dependence in these patients. The workshop highlighted issues such as epidemiology, obstacles to treatment, effects of nicotine smoking and cessation on drug metabolism, and the medications available to aid nicotine cessation. There was much debate, and often little consensus, during the case study discussions about the suitability of varenicline in this population due to concerns with psychiatric adverse effects. Most pharmacists did not consider varenicline to be a first-line option, while others were of the opinion that, if patients were closely monitored, it could be used effectively. Role plays were undertaken using brief tobacco cessation interventions applying the Five A Model: Ask about tobacco use; Advise every patient who uses tobacco to quit; Assess the patient’s willingness to make a quit attempt at the present time; Assist the patient in quitting; and Arrange for follow-up whenever possible. The key message from the workshop was that even brief interventions work and that we should always ask patients about their tobacco use as you never know when they may be ready to make an attempt to quit! Formulation technologies for antipsychotics Another valuable and relevant presentation was on dosage formulation technologies for antipsychotics by Dr Larry Ereshefsky, Chief Scientific Officer, California Clinical Trials, PAREXEL. He discussed a variety of new dosage formulation technologies that are being used for antipsychotics, including some that are available and others that are under development. In recent years, we have seen the introduction of extended-release oral preparations of the atypical antipsychotics, paliperidone and quetiapine. New long-acting injectable formulations of olanzapine and paliperidone are also available for clinical use in some countries. Inhaled drug delivery of loxapine was discussed and is under development. (Drug delivery via an inhaler using aerosolised small particle inhalation technology enables rapid delivery of drug deep into the lungs.) Pharmacists need to be aware of the formulation technologies of existing and new antipsychotics and also safety issues, for example, the post-injection syndrome, which has been observed in clinical trials with olanzapine pamoate depot injection. Adverse effects such as sedation, confusion, agitation, anxiety, dizziness, and dysarthria have been observed in a small number of patients following an injection. The signs and symptoms are consistent with olanzapine overdose and have

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occurred in less than 0.1% of injections and in approximately 1% of patients. Therefore, it is recommended that a post-injection monitoring period of three hours be undertaken and for the rest of the day, patients should be advised not to drive or operate heavy machinery, to be vigilant for signs and symptoms, and to be able to obtain assistance if required.2 Topiramate for PTSD-related nightmares I presented a poster on the follow-up results of a pilot study undertaken at the Repatriation General Hospital addressing the effects of topiramate for the management of nightmares related to post-traumatic stress disorder in Australian war veterans.3 The subjects who had completed the original study were followed up to assess whether the perceived benefits of treatment were maintained in the long term. We found that topiramate is a useful adjunct in the management of nightmares related to post-traumatic stress disorder, with benefits continuing for some in the long term. The poster was well received and garnered much interest from pharmacists working in Veteran Affairs in the USA. The meeting provided an excellent opportunity for education in psychiatry and neurology pharmacy and the opportunity to present research in an international forum. The next meeting will be held in San Antonio, Texas in April 2010. I would like to thank SHPA and Pfizer for financial assistance. Anita C Abarno, BPharm, MClinPharm, CGP Senior Clinical Pharmacist Repatriation General Hospital Daw Park SA 5041 E-mail: [email protected] References 1. Saks E. The center cannot hold: my journey through madness. New York: Hyperion; 2007. 2. Zyprexa Relprew (olanzapine pamoate monohydrate depot injection) Australian approved product information. West Ryde: Eli Lilly Australia Pty Ltd. Approved 3 March 2009. 3. Alderman CP, McCarthy LC, Condon JT, Marwood AC, Fuller JR. Topiramate in combat-related posttraumatic stress disorder. Ann Pharmacother 2009; 43: 635-41.

Quality in pharmacy education To the Editor, I concur and support the views expressed by Professor Roger Nation’s in a recent editorial.1 We have certainly reached a state of saturation when it comes to supply of pharmacy schools and possibly pharmacists in the workforce. The pharmacy workforce is changing as a result of an ageing population, public awareness about the quality use of medicines, medication costs, drug interactions and changes in our healthcare system.2 Quality pharmacy education in Australia needs to be defined clearly so that it can be measured. Several indicators such as examination results, extent of interaction with other professions, degree of innovative and flexible educational systems, facilities, interactions with government bodies, number of job opportunities and students pursuing higher education could be used as measures of quality in our profession.3

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To gain a broader picture of the quality of pharmacy education in Australia, an audit is needed of all pharmacy schools. The aim of this audit would be to advance pharmacy as a career by supporting these schools so that they can sustain future students and the pharmacy profession. Adoption of a quality assurance approach would result in recommendations that are more likely to be implemented and lead to rapid quality enhancement. Dr Hanan Khalil, BPharm, PhD Senior Lecturer/Pharmacist Academic Department of Rural and Indigenous Health School of Rural Health Faculty of Medicine, Nursing and Health Sciences Monash University Moe Vic 3825 E-mail: [email protected] References 1. Nation R. Pharmacy schools in Australia: when is enough, enough [editorial]. J Pharm Pract Res 2009; 39: 174-5. 2. Ridoutt L, Bagnulo J, Biason J. Analysis of secondary data to understand pharmacy workforce supply. Initial supply report. Pharmacy workforce planning study. Canberra: Pharmacy Guild of Australia; 2008. 3. American College of Clinical Pharmacy. A vision of pharmacy’s future roles, responsibilities, and manpower needs in the United States. Pharmacotherapy 2000; 20: 991-1022.

ASHP Midyear Clinical Meeting 2009 To the Editor, I attended the 44th Midyear Clinical Meeting of the American Society of Hospital Pharmacists from 6 to 10 December 2009 in Las Vegas, USA. The meeting is considered the largest gathering of pharmacists in the world and was attended by more than 20 000 pharmacy professionals. The keynote address was given by the actor, Dennis Quaid, who captured the audience’s attention with the riveting story of his newborn twins’ experiences with inadvertent near-fatal heparin overdoses in 2007. Following the incident, The Quaid Foundation was launched to minimise human error in patient care through systems changes. Emergency pharmacy Emergency pharmacy was one of the dominant features of the meeting. Dr Daniel Hays spoke on the application of lignocaine in the emergency department, medications used in rapid sequence intubation and code arrest, and discussed calculations used for pressor dosing and the management of daily fluid and electrolyte requirements for neonates and paediatric patients. One interesting session was a review of the fluids and factors used for resuscitation and traumatic haemorrhage. Specifically, the dosing of factor VIIa was discussed based on data from Europe (400 microg/kg), Israel (120 microg/kg) and the USA (41 to 90 microg/kg), and the cost considerations. There is no consensus in factor VIIa dosing and it is accepted that most adults weighing 50 to 100 kg will receive a single 5 mg vial, followed by another in 2 to 4 hours, if clinically indicated. As for toxicology, local antidote stocking guidelines and practical tips on the use of antidotes were presented. The epidemiology of antidote use, reported by the US poison centers were presented and the complexities associated with preparation and administration of

commonly used antidotes were discussed. Patients poisoned with toxic alcohol, e.g. methanol, ethylene glycol, in the US are treated with fomepizole (unavailable in Australia) instead of ethanol, dosed over 30 minutes at 15 mg/kg IV followed by 10 mg/kg BD for 4 doses, then 15 mg BD thereafter until ethylene glycol or methanol concentration is below 20 mg/dL. Dr Hays also moderated a session on Emergency Pharmacy Clinical Pearls, where emergency medicine pharmacists and residents presented short ideas of clinical practice in the emergency department, novel or innovative applications of clinical pharmacotherapy in unique circumstances or presentations. Gentle reversal of opioid intoxication can be achieved by nebulised naloxone (2 mg/3 mL for nebulisation) and a formulation of sodium bicarbonate can be used as eye irrigation to dissolve superglue (containing cyanoacrylates) inadvertently dropped into the eye instead of eye drops. The use of glucagon 0.25 to 1 mg IV for the management of oesophageal foreign body obstruction was also discussed and its overall use is questionable despite glucagon’s mechanism of relaxing smooth muscle of the lower oesophageal sphincter. In the emergency medicine networking session hosted by the Section of Clinical Specialists and Scientists, the management of acute agitation was discussed. The longstanding droperidol controversy and the increased interest in the use of atypical antipsychotics such as olanzapine in this context was discussed. An interesting combination known as B52 is used in some emergency departments for the management of highly agitated patients and consists of Benadryl (diphenhydramine 50 mg), haloperidol 5 mg and lorazepam 2 mg given in the same syringe intramuscularly or intravenously. Parenteral lorazepam remains unavailable in Australia. Attendance at the midyear meeting provided a great opportunity to network and exchange ideas on pharmacy practice and research in emergency medicine. I would like to thank SHPA and the Research and Development Grants Advisory Committee for funding this invaluable experience. Esther W Chan, BPharm(Hon), MClinPharm Honorary Research Fellow Emergency Department Austin Health, and PhD Candidate Department of Pharmacy Practice Centre for Medicine Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Vic. 3052 E-mail: [email protected]

Oncology pharmacy preparatory review course To the Editor, In May 2009 I attended the Oncology Pharmacy Preparatory Review Course, in Baltimore, Maryland. This course is designed to help oncology pharmacy practitioners prepare for the Board of Pharmaceutical Specialties Oncology Pharmacy Specialty Certification Examination.

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The course featured lectures, slides and handouts presented by clinical and educational experts. Attending the course enabled me to learn about the advances in haematology-oncology, meet with leaders and health professionals in haematology-oncology and to gain new ideas and skills. I also had an opportunity to network with like-minded pharmacists from around the world. The course was run by a faculty of experienced practising oncology pharmacy specialists, and the attendees were provided with comprehensive notes that included an overview of many common cancers, their staging and treatment, cancer screening and prevention, drug development, pharmacogenomics and statistics. The notes also covered the American legislation and administration that is required for the exam. The Oncology Pharmacy Specialty’s live educational program offered a focus on new developments in oncology pharmacy. The majority of delegates attended the course to updated their clinical knowledge, rather than to prepare and sit for the exam. I received a detailed workbook, with patient cases and practice-based self-assessment questions, and a copy of the instructional materials. Networking with other health professionals has enabled me to exchange ideas and broaden my knowledge base, which I have been able to share with my colleagues. I would like to thank Merch Sharpe & Dohme and the SHPA Research and Development Grants Advisory Committee for providing this invaluable opportunity. Maria Larizza, BSc(Hon), BPharm, MClinPharm, BA(Hon), BMTransST Senior Clinical Oncology Pharmacist The Alfred Melbourne Vic. 3004 E-mail: [email protected]

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Journal of Pharmacy Practice and Research Volume 39, No. 4, 2009.