s Recent series of torsade cases - no deaths and no pacemakers needed | I2P: Information to Pharmacists - Archive
Publication Date 01/08/2010         Volume. 2 No. 7   
Information to Pharmacists

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News Flash

Newslflash updates for August 2010

Neil Johnston

Regular updates from the global world of pharmacy.
Access and click on the title links that are illustrated.

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Feature Contribution

From Intern to Practising Pharmacist - PSA's New Vision

Neil Johnston

Practical experience is hard to acquire once you have finished your academic studies.
It is a process we all have to experience at one stage of our career.
The transition from being a student to a practising pharmacist can be a difficult time and unless early career pharmacists equip themselves for the new challenges they face, they may not be maximising their career opportunities.
It is also the type of program that could earn incentive payments for the workplaces providing the experience in the community.

Comments: 1

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Pharmacist prescribing in NZ flags other issues

Neil Johnston

The Pharmacy Council recently promoted a discussion document to encourage feedback from the health care environment on the impending legislative changes that are intended to provide the opportunity for pharmacists to prescribe.
The proposed legislation will enable suitably qualified postgraduate educated and skilled clinical pharmacists to prescribe from the drug tariff for patients under their care.
These pharmacists will have to work as part of a primary health care team and it is expected they will become an integral part of that team.
All very exciting for our profession to witness that there is a recognition that pharmacists are capable of stepping up to the mark and are worthy of greater responsibilities.

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Is a pharmacist in your team selection?

Neil Johnston

Pharma-Goss for August 2010
When selecting a team to participate in a primary health care review of the diagnosis and management of hypertension patient one would hope that a pharmacist would be a natural selection.
But in the case of a paper published recently in Australian Family Physician (http://www.racgp.org.au/afp/201007/201007howes.pdf) a pharmacist did not rate a mention in the panel set up to identify the problems associated with diagnosing hypertension and maintaining a dose that suited the needs of the patient with maximum adherence.

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Guild’s eRx clarification camouflages the facts!! Why hide the truth?

Neil Johnston

The thought that first struck me after reading ‘the clarification’ about the eRx Script Exchange on the editorial page of the May Issue of the Pulse+IT magazine was - Why is this clarification so necessary?
On the surface it seemed like a reasonable statement to make.
It read: “Clarification - in the March 2010 edition of Pulse+IT it was reported that the electronic prescribing service operated by eRx Script Exchange had received 7.5 million scripts "sent to the eRx script hub by prescribers" as of the middle of January.  
Omitted from the article was reference to a workflow that allows pharmacists to send repeat prescriptions to the hub for later retrieval by any pharmacist connected to the eRx system.
The volume of transactions quoted in the March 2010 article included such scripts, in addition to scripts sent to the hub directly by prescribers.”

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Guild Takes Aim at Gillard & Abbott Over 5TH CPA

Neil Johnston

In The Australian Friday 23 July (Political creed: do no harm) Emma Connors reported that “sometime in the next four weeks both Julia Gillard and Tony Abbott are likely to sign a letter promising their support to a group of 5000 small business owners whose public standing allows them to extract an extraordinary pledge.”
She reported that the Guild had “asked the leaders of  both sides of politics to agree that the terms of the recently enacted Fifth Community Pharmacy Agreement will be upheld, including the all-important promise to keep supermarkets out of pharmacy”.

Comments: 4

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The failure of Gollmann-Bouw: Are their products what our market wants?

Neil Johnston

Editor's Note - 15th November 2012:
When this article was first published in August 2010, Gollman-Bouw had entered into liquidation following a very turbulent period under the stewardship of Mark Bouw, managing director of the Australian enterprise.
Since that date the automated dispensing market has settled down and is now demonstrating steady and solid growth.
New people have entered into an agreement with German company Gollmann Systems and they have no relationship with any of the people associated with the former entity.
Many of the initial teething problems have been overcome and a better understanding of the Australian pharmacy market has emerged.
Gollmann Systems are globally competitive and contain innovations not seen in some of their competitors.
Any prospective purchaser should short-list this product when seeking a solution for their pharmacy.

Comments: 4

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Private Labels Finding Favour

Neil Johnston

Since the global financial crisis began to bite, Australians have shifted more of their weekly purchases into private label.
In respect of the $70 billion pa food market, private label currently accounts for 23%, with the prospect of moving to 30% within five years.

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Food as Medicine

Neil Johnston

Many foods have health giving and medicinal properties.
Indeed, i2P reports frequently in its Preventive Medicine section, regular discoveries where food can be used to support various health conditions.
For example, raw beetroot juice has recently been found to be effective in treating high blood pressure (it contains nitrates) and is as effective as some antihypertensive drugs. Cinnamon is another food that is useful for diabetics, where cinnamon appears to have effects similar to metformin i.e. it sensitises insulin.
Ayurvedic medicine, developed in India over centuries, encompasses the use of many delicious foods enhanced with herbs and spices.
Ayurveda is an ancient Indian healing system. The central philosophy is that illness is caused by an imbalance of the body's three vital energies, or 'doshas'. Ayurveda uses a range of treatments including yoga, massage, acupuncture and herbal medicine.
More information can be found at the Australian government site - HealthInsite. http://www.healthinsite.gov.au/topics/Ayurvedic_Medicine
For Ayurveda diet and health information that can get you started, try this site http://www.joyfulbelly.com

Comments: 2

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Hung Parliament Means Listen to the People

Neil Johnston

People involved in e-health are bitterly disappointed with the "hung parliament" result.
At least Labour had a vision with its national broadband roll-out, even if it wasn't properly articulated in regard to cost.
Some proponents argue that the cost matters little - it is the advantage given to Australians who want to be pioneers in e-health. Opportunities could be lost and they may be priceless.
i2P went looking for some informed comment on the subject and found some excellent commentary written by Paul Budde, a telecommunications analyst.
His commentary follows:

Comments: 1

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Scientists tap into Antarctic octopus venom

Neil Johnston

Researchers have collected venom from octopuses in Antarctica for the first time, significantly advancing our understanding of the properties of venom as a potential resource for drug-development.
The study, conducted by an international team of researchers from the University of Melbourne, the Norwegian University of Technology and Science and the University of Hamburg, provides the first insight into the properties of Antarctic octopus venom.
It has also revealed the existence of four new species of octopus.

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Peruvian plant offers hope for sex lives of diabetic women

Neil Johnston

The effects of diabetes on organs such as the heart, eyes and kidneys are relatively well known, but women are now being warned of its potential to cause damage in another way – to sexual performance.
Victoria University’s Professor Lily Stojanovska and Dr Michael Mathai are conducting a study to assess the potential for improving sexual function in women with type 2 diabetes by taking a supplement from a plant traditionally used for this purpose in Peru.
The root of the plant Maca (Lepidium meyenii), which grows in the Peruvian Andes, has been used by locals for centuries, where it is reported to enhance fertility and to boost energy levels.

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Clinical Training for Health Profesionals

Neil Johnston

Some years ago an Australian hospital pharmacist pioneered wound management in Australian hospitals and went on to develop courses to train community pharmacists interested in setting up a specialty wound management clinic in their pharmacy setting.
This type of service initially established itself in a restricted number of pharmacy settings, but gradually faded away due to the pressure of PBS dispensing.
Now the opportunity is reappearing in WA at Curtin University with a purpose built facility established to train all health students (including pharmacy).
And here is the dilemma.
Many pharmacists would like to be involved in this type of activity but most community pharmacies are not physically designed to accommodate this service.
However, with the future development of Primary Health Care Organisations (PHCO's) under way, it may be possible for pharmacists to be part of the wound management team in that type of organisation.
Nicola Roxon is contributing $380,000 towards the project and is expected to be operational within three months.

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New hope for cerebral palsy prevention

Neil Johnston

University of Adelaide researchers are a step closer to finding a link between genetic susceptibility to cerebral palsy and a range of environmental risk factors during pregnancy, including infections and pre-term delivery.
During National Cerebral Palsy Awareness Week (August 1-7), Professor Alastair MacLennan from the University's Robinson Institute says their research shows that pregnant women who are genetically susceptible to infections and other environmental hazards could trigger cerebral palsy in their unborn babies.

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UK Vending Machines Trialled

Neil Johnston

Prescription vending machines are being deployed in the UK Sainsbury pharmacy chain. This is being done in conjunction with the normal in-store pharmacy service,
and is being promoted as an additional service for those who would prefer it.
It is not an automated dispensing solution.

Comments: 2

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Research breakthrough on the question of life expectancy

Neil Johnston

Why do we grow old and what can we do to stop it? This is the question asked by many, but it appears that we are now closer to an answer thanks to new research published by Monash University researcher Dr Damian Dowling.
According to the research published in the August edition of the prestigious journal, The American Naturalist, a small set of genes in mitochondria (a membrane-enclosed organelle found in most eukaryotic cells), passed only from mothers to offspring, plays a more dynamic role in predicting life expectancies than ever previously anticipated.

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Liesel Wett - the new CEO for the PSA

Neil Johnston

In a shrewd management decision, the Board of the Pharmaceutical Society of Australia has announced the appointment of Liesel Wett as the organisation’s new Chief Executive Officer.
Ms Wett, who is currently Deputy Chief Executive Officer and Chief Operating Officer of the Australian General Practice Network, is expected to take up her appointment on 1 October 2010.
Given that the PSA will need to develop closer and stronger ties with GP organisations, this appointment may well prove to be critical for the future professional development of pharmacists.
Pharmacists will be enabled to get inside and understand GP thinking, guided by Liesel Wett.

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Inflammation in Fat Cells Causes Insulin Resistance

Neil Johnston

Inflammation-causing cells in fat tissue may explain the link between obesity and diabetes, a team of Walter and Eliza Hall Institute researchers has shown.
The discovery, by Professor Len Harrison and Dr John Wentworth from the institute’s Autoimmunity and Transplantation division, opens the way for new anti-inflammatory treatments that prevent insulin resistance (where the body is unable to respond to and use the insulin it produces) and other complications associated with obesity.

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Cost Price Prescriptions - The Next Step?

Neil Johnston

The UK has started a new phase in private prescription discounting – no mark up on the drug and 50% off the dispensing fee.
“Millions could be saved every year if private prescription mark ups are abandoned, according to the Superdrug superintendent pharmacist.
Superdrug will dispense all private prescriptions with no mark up on the cost of the medicine, the company announced this week (3 August 2010).
It is also halving its minimum charge for dispensing medicines to £2.25.”

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The country can't face the technological future through copper wire

Neil Johnston

An opinion provided by the University of Sydney
By Professors Ben Eggleton and David Moss

Those who think our country can do without the national broadband network clearly do not fully understand the potential such a network offers to Australians. While other countries scramble to find ways to meet this exploding demand for global bandwidth, the opposition is wringing its hands and debating the need.
The network will do three things for Australia: it will pay for itself, it will stimulate the innovation economy and it will have multiple applications.

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Garlic may play vital role in treating hypertension

Neil Johnston

A University of Adelaide study shows that aged garlic extract may help lower blood pressure in the 3.7 million Australians who suffer hypertension.
Research trials by Dr Karin Ried and her colleagues from the University's Discipline of General Practice show that garlic could be used as an adjunct to conventional drugs for hypertension.
However, raw or cooked garlic, and garlic powder are not as effective in treating high blood pressure as aged garlic extract.

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Solar Diesel Power Station - World First in WA

Neil Johnston

The world's first solar-diesel power station has opened in Western Australia's Pilbara region at Marble Bar, known for its record high temperatures.
WA's Mines and Petroleum Minister Norman Moore opened Horizon Power's Pippunyah Solar Diesel Power Station on Friday.
The new $34 million station is powered by the biggest sun-tracking solar panel farm in Australia.

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Complementary Medicines Surveyed

Neil Johnston

 Recently, a research report was published online in BMC Complementary and Alternative Medicine that highlighted Australian consumer attitudes towards complementary medicines and pharmacists selling complementary medicines.
An abstract is published below.
Consumers have indicated in earlier surveys that they wanted pharmacists to be the primary source of information for them and to keep a range of products that they could feel safe with.
The profession initially responded to those needs with the PGA setting up a College of Clinical Nutrition and many pharmacists (including this editor) completed the Advanced Diploma of Clinical Nutrition (Pharmacy).
Unfortunately, the college was closed and an alternative resource was never re-established.
People who did receive training in the use of nutritionals gained a new perspective in respect of practicing their profession and tended to work in the area of preventive medicine when an opportunity presented itself.
We have again asked Mark Coleman to comment on the survey and his report appears below the article abstract.

Comments: 12

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Recent series of torsade cases - no deaths and no pacemakers needed

Dr Andrew Byrne & Associates

articles by this author...

A Harm-Minimisation Research Perspective: Dr Byrne (and his associates) advocate for better policies which are proven to reduce risks for drug users and the general community, under a framework in parallel with Australia’s official policy of harm minimisation.

Ventricular arrhythmias in patients treated with methadone for opioid dependence. Hanon S, Seewald RM, Yang F, Schweitzer P, Rosman J. J Interventional Cardiac Electrophysiology 2010 28:19-22After a single case report in 2008, it is to the credit of this group to have now added 11 more consecutive cases of ventricular arrhythmias in methadone patients treated at the Beth Israel Medical Center in New York over a two year period. This represents all known hospitalised referrals from the largest clinic system in America numbering over 6000 patients in 18 locations. It comprises some of the earliest such clinics with some patients who commenced treatment in the mid-1960s.

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After a single case report in 2008, it is to the credit of this group to have now added 11 more consecutive cases of ventricular arrhythmias in methadone patients treated at the Beth Israel Medical Center in New York over a two year period. This represents all known hospitalised referrals from the largest clinic system in America numbering over 6000 patients in 18 locations. It comprises some of the earliest such clinics with some patients who commenced treatment in the mid-1960s.

Two of the twelve reported patients already had pacemakers in place and their presentation was due to (successful) activation of the device. They were admitted to hospital for observation due to ‘storm’, meaning more than two malignant arrhythmias in a 24 hour period.

Three of the remaining 10 did not have torsade but other ventricular arrhythmias not known to be associated with QT prolongation. Thus seven torsade cases were diagnosed from a ‘mature’ clinic population of 6000 patients over a two year period. Eight of ten tachycardia cases had precipitating factors (apart from age and methadone) including potassium and/or magnesium disturbances (4 cases), pneumonia (2 cases) and prescription medication likely to prolong QT interval (4 cases). The mean age of those with no other risk factors was 56 years. No urine toxicology results are detailed, nor are alcohol/drug histories given for these worrying cases. A co-author informed me that none of these patients was HIV positive.

The article states: ‘An increasing number of cases of methadone-associated Torsades de Pointes (TdP) have been reported over the last several years [3–11]’. Of these references, however, only three actually report a case of TdP (Krantz 2002; Pearson 2005; Esses 2008). None of the other references report tosade cases (Wedam, Ehret, Byrne, Justo, Fanoe, Chugh). They are either commentaries, reviews or reports of QT prolongation without torsade de pointes. There have indeed been a small number of recent individual reports of TdP, nearly all with precipitating factors in high risk patients (Iskander, Lamont, Luthi, Prosser, Puri, Pimentel, Routier and Wong, one case each).

Although we are only given limited clinical details of these cases, this new report of 12 cases is pivotal. It is the first large hospital series reported since the subject came to prominence with Krantz’s remarkable and unique retrospective series of 17 cases in 2002. Despite initial fears, such a series has never been replicated elsewhere in the 8 years since. It is disappointing that Krantz has never reported any clinical follow-up from his seminal 17 cases of torsade from 2002.

While a prevalence rate of torsade de pointes arrhythmia in methadone prescribed patients has not been published, this series from New York is probably our best indication to date. Torsade appears to be absent in young people and is extremely rare in the long-term methadone maintenance patient group. It is disappointing that despite anecdotal reports from many other great metropolitan hospitals in America, few if any have reported their torsade experience formally in this way.

Because of the rarity of this syndrome it has been difficult to determine the best way to approach therapy. We can best learn by combining experiences through such case reports. This present series allows us to add to the other ~100 reports in the literature, about 60 of which are detailed reports.

The New York findings are consistent with other reports, including:

* a mortality of zero

* no new patient in this current series required a pacemaker (two had complications of previous ICD’s)

* one third were either asymptomatic (n=2) or minimally symptomatic (n=2, ‘pre-syncope’)

* transition to buprenorphine was only possible in a minority (25%)

* dose reductions were possible in almost half, most being associated with resolution of the arrhythmia

* age range 43-61, mean 54 years

* 75% of subjects were male

While optimal treatment of torsade remains to be determined some factors seem to be agreed. Giving potassium and magnesium infusions seems effective as an early measure, following cardioversion where indicated. Some cardiologists use isoprenaline or other inotropic/chronotropic agents to prevent the bradycardia which is often a prelude to the torsade tachycardia. Pacing with implantable cardiac defibrillator (ICD) was used in 25 of 62 cases reported in the literature.

Reducing methadone doses or transfer to buprenorphine may be feasible in certain cases. Long acting morphine may be useful in some subjects, initially as an in-patient measure. However, this may not be practicable long-term due to cost and/or regulatory restrictions outside of specialist pain management settings.

Doing regular cardiographs, in some cases for over 20 years, would have been unlikely to assist these subjects.

Comments by Andrew Byrne .. http://methadone-research.blogspot.com/

References on web version: http://methadone-research.blogspot.com/2010/07/largest-series-of-torsade-cases-in-mmt.html

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