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Pharma News
Hospital News
Health Politics
James Ellerson: GPs were the ‘gatekeepers’ to the health system. Will they remain so? | open full screen
Chris Wright: Health: The Pollies are playing us as well as Orianthi plays the guitar. | open full screen
Climate Change
GP Super Clinics
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Newslflash updates for June 2010
Regular updates from the global world of pharmacy.
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Feature Contribution
Do the Maths - 1200 Graduates a Year and Increasing
Pharmacists graduating within Australia must have a reasonable assurance that on graduation they will have some form of a job available for them, after due diligence and reasonable effort on their part to get themselves recruited.
The current maths do not stack up - 5000 pharmacies to accommodate 1200 graduates nationally, and increasing.
Who is responsible for the planning for graduates?
GPs were the ‘gatekeepers’ to the health system. Will they remain so?
It’s often hard to tell which party is in favour of what outcome when reading some of the media coverage on doctor, pharmacy, nurse practitioner prescribing issues. Here are a few examples to ponder:
• the Guild is opposed to pharmacist prescribing
• pharmacists and nurse practitioners are to be given limited prescribing rights
• most GPs do not actually consult with a patient before issuing a repeat script.
Is eHealth critical to navigating the world of primary care?
Primary health care reform is firmly on the political agenda. For reforms to succeed they must be underpinned by the successful deployment of ehealth; absolutely.
The last decade has witnessed a major lost opportunity for ehealth in Primary Care. Many hundreds of millions of dollars have been wasted on unrealistically ambitious and poorly managed ehealth projects; many of which have failed.
Aptly named Primary Health Care Organisations (PHCO), recently inappropriately renamed ‘Medicare Locals’, will be the centre point of the reform process. Consequently a palpable sense of urgency has developed around ehealth as its central role in the health reform process becomes increasingly apparent to politicians and bureaucrats.
PSA Future of Pharmacy-Technicians to manage dispensing
Comment has been recently made in pharmacy media on the PSA Issues Paper on the “Future of Pharmacy in Australia” in respect of the upskilling of dispensing technicians to dispense without pharmacist oversight.
Comments offered on this aspect included reduced job opportunities for pharmacists, pressure to lower dispensing fees, opportunity to develop clinical services e.g. the ability to perform HMR’s.
No doubt more comment will follow as the paper is digested and potential flow-on impacts are thought through.
Writers will be participating through the pages of the i2P e-magazine to hopefully help build the future version of this PSA paper.
Health: The Pollies are playing us as well as Orianthi plays the guitar.
Our politicians are spinning like fury as we head towards the election and despite the fact their gift for spin doesn’t match Orianthi Panagaris’ gift for playing guitar they are getting away with electoral blue murder.
As for “fixing” the health system, the rhetoric is never matched by performance. After all, it is questionable that “fixing” health actually translates to votes, simply because the money required to make an impact is too great an amount compared to the votes gained…besides “fixing” is subjective anyway.
What is it with pharmacy?
The colleges are churning out Pharmacists at a rate that would embarrass the most discerning “people-smuggler”……..
Apologies for the errant humor leading to an election.
Some 1,200 bright-eyed and bushy-tailed fine and mostly young pharmacists are hitting the job market and will somehow try to squeeze into 5,000 pharmacies.
Worse, a similar number will follow them fairly smartly.
What’s it all about, I wonder?
Looking for answers
Everyone, it seems, is looking for answers. For most there are none “out there”. Those who ask the right questions generally find the right answers “within”.
Solutions abound, looking for problems. Few can define and even fewer recognise the nature and presence of specific problems. Resources are being liberally allocated to furnishing, deploying or paying for preset solutions. Disappointment and dissatisfaction seem inevitable.
Experts are readily accessible. Expertise is harder to find. The business landscape appears to be lush with new green shoots, yet barren. Much like the desert and the Lake Eyre regions of central Australia.
The climates of regions throughout the world are changing. Temperatures are rising. Record cold snaps are also being recorded. Extended dry spells are evident, offset by deluges of flooding proportions.
Prognostications by some economists conclude “boom times” have arrived or are on the near horizon. Many consumers have obviously not heard or read of the confidence building forecasts. They are constraining purchases and outlays. Retailers, particularly smaller entities, are confused, and are finding trading is tough.
In recent times we have worked with clients from a broad spectrum of sectors producing formats, templates and frameworks which enable them to “look within”.
Real riches are being rediscovered, refined and celebrated. Positive and embracing corporate cultures, are being revisited and pride inculcated, because of what made entities great and competitively advantaged in the first instance.
Distinctive symbols and myths are being recognised, valued and applied for internal cohesion, self motivation and for external profiling.
The article text which features later in this transmission unveils and outlines encouraging lessons and principles on the role and nature of a positive corporate culture.
I commend it to the former executives, the players and besieged supporters of the once high achieving, now disgraced Melbourne Storm Rugby League team.
Barry Urquhart
NAPE begs more questions than answers- for the moment
The ideal of having quality continuing pharmacy education, delivered in digestible “bite-sized” chunks plus convenience of delivery at an economical cost has been a dream for pharmacists for as long as I can remember.
With the advent of the new Australian Pharmacy Board there will be requirement for all pharmacists to undertake suitable education to maintain their registration.
While there are many acceptable education streams coming from the Pharmaceutical Society of Australia (PSA), the Pharmacy Guild of Australia (PGA) and the Australian College of Pharmacy Practice (ACPP), there is not a high degree of planning to anticipate all pharmacist needs.
For example, the delivery of professional services for a fee – there is no identifiable pathway enabling individual pharmacists to develop a professional practice that could be incorporated into a community pharmacy, a primary health care organisation, a medical centre or other suitable location.
Hmmm, I’m not convinced
A Woolworths “spokesman” (they are all still so very alpha at Woolies) has come out (excuse the expression) and declared the loss of interest in not only their “pharmacy” type trademarks but the industry of pharmacy itself.
980218 Pharmacist at Woolworths and 980219 PHARMACIST @ WOOLWORTHS, both previously registered trade marks, have been cancelled.
3Naturopathy and my Doctor.
To my pleasant surprise the family doctor offered a choice to address a painful problem highlighted by scans.
Acupuncture or an anti-inflammatory drug?
Acupuncture any day thank you, without the fries.
2 
Better patient advice loses out to costly prescription errors
A University of Otago study which shows pharmacists spend too much time seeking clarification for minor prescription errors has prompted a call for greater awareness among doctors and prescribers of this time-wasting problem.
Lead author and School of Pharmacy Senior Lecturer Dr Rhiannon Braund says the study of 20 Dunedin pharmacies found that in most cases unnecessary minor bureaucratic errors were the reason for pharmacists needing to confirm the intent of prescribers - usually doctors.
Study shows Australian quality of life varies widely
A survey of 5000 Australians conducted by the University of Technology Sydney has shown middle aged people express the lowest level in quality of life compared with people in their early 20s or mid 60’s.
The finding which throws the ‘life begins at 40’ cliché into serious doubt is among a number of revelations gained from the study.
Findings of the research will be discussed in a public lecture held at the UTS Great Hall on Tuesday 25 May 2010. Details for the lecture which is open to the public for free can be obtained from the UTS web site www.uts.edu.au/new/speaks/2010/May/2505.htm
Public participation heats up on climate change
Australians believe that climate change is here to stay, but their expectations about the severity of change fall well short of what scientists predict.
This is one of the key findings from a three-year study led by The Australian National University. The Climate Change and the Public Sphere project has interviewed more than 100 randomly selected citizens from the ACT and Goulburn about their views on climate change in various, increasingly severe, situations and how they are likely to react to it in the future.
Killed by cold: heart and stroke deaths peak in winter
* Perth and Sydney lead the country in winter heart-related deaths
* Tasmanians cope best with the cold
* Brisbane not far behind Sydney for winter deaths
* Darwin fares the best because it doesn't get so cold
Rates of cardiovascular disease increase dramatically in Australian winters because many people don't know how to rug up against the cold, a Queensland University of Technology (QUT) seasonal researcher has found.
Traumatic brain injury linked to sleep disturbance
A Monash University study has shown that sleep disturbances and depression symptoms are common among people who have suffered Traumatic Brain Injury (TBI).
The team of researchers from the School of Psychology and Psychiatry measured in a laboratory setting the sleep of 23 patients with TBI with 23 healthy people who had not suffered trauma.
Study leader, Associate Professor Shantha Rajaratnam said patients with TBI showed increased sleep disturbance and reported poorer sleep quality, and higher anxiety and depressive symptoms than healthy volunteers.
Blood Thinners May Prevent Malaria
New treatments for malaria are possible after Walter and Eliza Hall Institute scientists found that molecules similar to the blood-thinning drug heparin can stop malaria from infecting red blood cells.
Malaria is an infection of red blood cells that is transmitted by mosquitoes.
The most common form of malaria is caused by the parasite Plasmodium falciparum which burrows into red blood cells where it rapidly multiplies, leading to massive numbers of parasites in the blood stream that can cause severe disease and death.
PAC 10- A Focus on Pharmacy Practice Change
Pharmacy practice must shift its primary mission from supplying medicines to helping people make the best use of medicines in order to meet the needs of the public and ensure its survival as a health profession.
This is the view of leading US pharmacy expert Professor William A. Zellmer who will present on the topic of The Imperative for Change in Pharmacy Practice at PAC10 in October this year.
Drug Company Battles with NZ Pharmacy Guild
In a recent news item reported in the New Zealand Stuff.co.nz highlights a drug recall problem that had significant associated costs involving community pharmacy participation.
It is a problem that could occur within Australia and is currently before the courts in New Zealand.
The problem does reflect on the existing culture within the pharmacy profession where for too long pharmacists have virtually donated their services in instances where there should have been an expectation of payment for a professional service.
PGA (Australia) could monitor the legal process in New Zealand and adopt a protocol, if the result proves favourable to pharmacy.
The story (found online here) follows below:
Hmmm, I’m not convinced
A Woolworths “spokesman” (they are all still so very alpha at Woolies) has come out (excuse the expression) and declared the loss of interest in not only their “pharmacy” type trademarks but the industry of pharmacy itself.
980218 Pharmacist at Woolworths and 980219 PHARMACIST @ WOOLWORTHS, both previously registered trade marks, have been cancelled.
3Sunlight shines on clean energy future
Dr Zhiguo Yi and Professor Ray Withers have found a simple inorganic compound can efficiently oxidise water to release oxygen.
The production of clean energy and the treatment of waste water are set to become easier thanks to ANU researchers.
The scientists – Dr Zhiguo Yi and Professor Ray L Withers of the Research School of Chemistry at ANU, along with colleagues from Japan and China – have demonstrated that a simple inorganic compound, silver orthophosphate, can efficiently be used to oxidise water with only the power of light.
The oxidisation process can be used to convert solar energy to clean energy or break down contaminants in water.
The research is published in Nature Materials.
The Ascendancy of Warwick Plunkett
Prior to negotiations commencing for the Fifth Community Pharmacy Agreement (5CPA) the Pharmaceutical Society of Australia (PSA) and the Pharmacy Guild of Australia agreed that the two organisations would present a unified front in their dealings with government.
That did not happen and many details of the 5CPA were completed in secrecy and without the appropriate input by the PSA.
Explanations were later offered by the PGA, but they rang a little hollow and were certainly outside of the spirit of a unified front.
Certainly, on the surface it appears that the PGA did not honour an agreement and was prepared to discount their formal agreement to the extent that it seemed not to exist at all.
The news item reporting the rift between the two organisations follows and Mark Coleman has been asked to provide a commentary at the foot of this news item.
"Wet Brain: Alcohol and the Brain".
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PDF version | Dr Andrew Byrne & Associates |
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. | |
This is the latest report below from Dr Byrne who has resumed the series at Concord Hospital. Dr Paul Haber, the presenter, oversaw the methadone clinic research conducted in the Alfred Hospital out-clinic in 2000-2001 as part of the national methadone project which showed that methadone maintenance was comparable or superior in primary care than clinics. This laid a basis for the expansion of methadone provision by community pharmacies. Analysing the figures, from about 22,000 methadone maintenance in 1997, it had grown to > 40,000 in 2002 and may be near 45,000 in pharmacies. Over that time of course, heroin availability has fallen markedly.
Wet Brain: Alcohol and the Brain - delirium, confabulation, amnesia, and collapse.
In this seminar, Dr Paul Haber looked at the ways alcohol affects the brain, both “direct” effects (intoxication, dependence, withdrawal, hallucinosis and sleep disturbance) and “indirect” effects, ranging from Wernicke-Korsakoff Syndrome to head injury, stroke, intracranial haemorrhage and epilepsy.
The corpus callosum, cerebellum and mamillary bodies are areas of the brain most prone to the effects of alcohol, but indeed the whole brain is sensitive to the effects of alcohol. The extent of this susceptibility is perhaps best seen in the globally impaired brain development of the foetal alcohol syndrome.
(Dr Haber reminded us to be vigilant: FAS is often first diagnosed in adulthood, and that even late identification and management may improve people’s functioning in life.)
Multiple pathology is the rule rather than the exception, even when only alcohol is the injurious agent (as opposed to injury, cerebrovascular disease, hypertension, thiamine deficiency etc).
While dopaminergic and opioid neurochemical in the “brain reward pathways” underlie the phenomena of dependence and craving, the syndrome of alcohol withdrawal results from alcohol’s effects at ligand-gated ion channels, especially GABA-A & NMDA receptors. Adaptive changes in response to chronic alcohol consumption, including desensitization of GABA-A and up-regulation of NMDA receptors, lead to the hyperexcitable state of the CNS in alcohol withdrawal.
Alcohol withdrawal seizures are an important example of this CNS hyperexcitability. They tend to occur in the first 24 hours of alcohol withdrawal and 90% occur within 48 hours. They occur in 10% of hospital series of alcohol withdrawal (they may be less common in community practice). Risk is proportional to the prior level of alcohol consumption. They are generalised tonic-clonic in 95%, and most are uncomplicated and self limiting, however they are multiple in 25%. The EEG is normal in 90% of cases. Seizures are more likely to happen in people who are metabolically unwell. Alcohol also predisposes to seizures in epilepsy and to brain injury which can be a cause of seizures.
Benzodiazepines are effective treatment for alcohol withdrawal (see Cochrane review, Amato et al 2010). Further, in a study of chronic alcohol users who presented to Boston emergency departments after a witnessed, generalized seizure, treatment with intravenous lorazepam was associated with a significant reduction in the risk of recurrent seizures (D’Onofrio et al, N Engl J Med 1999 340:915-9.)
We were reminded that in ambulatory settings, claims to have had alcohol-related seizures may more commonly come from people trying to get benzodiazepines, than from true cases.
Dr Haber mentioned alcoholic hallucinosis, a rare syndrome (0.6% hospitalised alcoholics; Soyka 2008) which needs to be distinguished from the hallucinations of delerium tremens (DTs) and also from alcohol-related psychotic disorder. They are typically auditory hallucinations, and may be accompanied by paranoia, but with preserved insight. The key to diagnosis is that they occur with a clear sensorium. They may occur while drinking and persist during withdrawal, but the majority settle with abstinence. (Dr Peter Tucker however reminded us that most cases of people hearing voices while drinking alcohol will be chronic schizophrenics, as this condition is relatively common and many schizophrenics “self-medicate” with alcohol and other drugs).
Another organic brain syndrome related to alcohol is hepatic encephalopathy. There may be impaired cognitive function, but importantly, this is reversible in early stages, and treatment with lactulose is effective. Most people with hepatic encephalopathy are jaundiced, but bilirubin excretion may be preserved: the mechanism of encephalopathy involves porto-systemic shunting.
The essential neuropathology of direct alcohol-related brain damage is white matter atrophy with reduced brain weight. Myelination and axonal integrity are involved. There can also be grey matter neuronal loss, and large neurons are most susceptible, the same neurons affected by Alzheimer’s disease and ageing. These changes are reversible in experimental animals with alcohol abstinence.
Alcohol is toxic to the brain independent of thiamine deficiency, but the latter probably causes most of the problem we see in clinical practice, including the Wernicke-Korsakoff syndrome (WKS).
Thiamine pyrophosphate is a co-factor in oxidative decarboxylation of á-keto acids. Plant seeds are the major dietary source, but thiamine is removed in processing of white flour and rice. Dr Haber mentioned Dr Clive Harper, of Sydney University, who lead the battle to supplement Australian flour with thiamine, leading to a reduced incidence of deficiency states.
Dr Harper’s recent review of “The neuropathology of alcohol-related brain damage” (Alcohol. 2009 Mar-Apr 44(2):136-40.) is available free on Pubmed at http://www.ncbi.nlm.nih.gov/pubmed/19147798
Thiamine is highly water soluble, and is lost in cooking. Average requirements are 1 mg/day. Heavy users of alcohol have reduced dietary intake, reduced absorption and increased requirements, partly owing their unbalanced, carbohydrate heavy diets.
The classic triad of Wernicke’s enecephalopathy is present in only 10% of cases, so many cases probably go undiagnosed, or are first diagnosed at autopsy. Confusion is the most common manifestation, with ataxia present in 23% and nystagmus in 29% (with or without horizontal gaze or other palsy)
Wernicke’s is a medical emergency: rapid treatment with parenteral thiamine is highly successful, as the changes are largely reversible, while delayed treatment may result in permanent severe disability.
A Cochrane review concluded there is insufficient evidence to guide treatment with thiamine (other than to say 200mg better than 5mg!). However, the usual practice is to give it prophylactically in all alcohol users admitted to hospital, as 100mg tds 3-5 days, then 100mg daily until abstinent >3 months (which may mean indefinitely). Thiamine is given parenterally if the patient is unwell or receiving IV fluids, and parenteral treatment should always commence prior to IV glucose, as a carbohydrate load may precipitate Wernicke’s enecephalopathy. If there is any suggestion of confusion or WKS, thiamine should be given 100mg tds by IVI or IMI.
The chronic phase of the Wernicke-Korsakoff syndrome, Korsakoff’s psychosis, is dense anterograde amnesia with confabulation, apathy and gross functional impairment, reflecting damage to the anterior nucleus of thalamus. Estimated prevalence is 12% in alcoholics, so it is still common. It may overlap with features of alcohol-related cerebrocortical degeneration, including frontal lobe syndrome (with impaired abstract thinking and executive function, disinhibition and personality change) and pre-senile dementia.
Diagnosis requires a history of harmful alcohol use, and exclusion of other explanations for symptoms (eg diazepam use). Bed-side tests of cognition like the Mini Mental State Examination are usually sufficient, however MMSE is not sensitive to early disease (Manning et al 2007). The Clock test is moderately sensitive and specific and very quick and very cheap! (Pinto and Peters Dement Geriatr Cogn Disord. 2009 27(3):201-13). Formal neuropsychiatric testing is useful to determine functional capacity and in doubtful cases, but is costly, time consuming and difficult to do in this population. Dr Haber considers it is over-ordered.
The etiology of alcohol-related cerebellar damage, like Wernicke’s, has a nutritional component, and these syndromes may overlap, or even form a continuum; but unlike Wernicke’s, cerebellar damage evolves subacutely over months & is often not fully reversible. Characteristically, there are wide-based stance and gait, with the legs worse affected than the than arms, while speech and ocular movements are relatively spared. The cerebellum also involved in perception and executive functions and memory, so cerebellar damage may contribute to cognitive deficits. Treatment involves alcohol abstinence, thiamine and multivitamins.
Alcohol is associated with stroke by a J-shaped curve, like cardiovascular disease. Moderate consumption lowers stroke risk but there is 4-5 times increased risk at high levels of consumption. Heavy drinking is associated with smoking and with hypertension. Brain haemorrhage (arachnoid, intracranial and subdural) needs to be considered in any confused or obtunded person with a history of harmful alcohol use. A rare but important alcohol-related problem is central pontine myelinolysis, causing quadriparesis and locked in syndrome, when hyponatremia is too rapidly corrected. Diagnosis is confirmed by MRI.
Finally, an estimated 50-75% of traumatic brain injury is associated with substance use, but 50% of cases do not present to hospital, and previous brain injury is often overlooked in clinical history and examination. Alcohol use is associated with poorer prognosis and delayed recovery from brain injury which in turn is associated with poor outcomes of alcohol treatment.
Indeed, most “talking therapy” is cognitively intensive and may be beyond the capacity of people with alcohol-related brain damage, in terms of reasoning skills, attention skills and memory. One needs either to adapt the program or discontinue it. Rehabilitation services present a particular challenge: the patient who most needs this treatment is least likely to benefit from it.
CASE STUDIES:
In the second half, three Case Studies of the Bach Siblings were worked through, to show the need to consider a range of causes for collapse, confusion, and ataxia in heavy drinkers.
Wilhelm Friedrich Bach, a 58 year old male disability pensioner was brought in to the Emergency Department by ambulance, hypothermic (oral temperature 34) after being found lying supine on the footpath in an inner city street, smelling of alcohol. He had been drinking daily since the age of 25.
He was conscious with no neurological deficit but had a deep laceration to his scalp. There were marked hepatomegaly and epigastric tenderness. Haemoglobin was 94 and WBC 13.9 x 109/L. LFTs were consistent with alcoholic hepatitis. Coagulation parameters were normal. Cerebral CT was reported normal.
Hypotheses for his collapse included alcohol intoxication, sepsis, myocardial infarction, gastrointestinal bleeding, head injury, seizure, other drug use ….
Oral thiamine 100mg bd and alcohol withdrawal scale (AWS) were started, reaching a maximum 7 on the 3rd day of admission. Oral diazepam was given, totalling 20mg, 30mg and 60mg on the first 3 days. On the 4th day the patient showed flat affect, slow speech and had a gross tremor of both hands, and a wide-based ataxic gait. Mini Mental State Examination score was 24/30. The patient was disoriented in time and place with poor performance evident in short term recall, abstract thinking and construction.
The differential diagnosis of his ataxia and confusion included cerebellar disease, Wernicke’s and alcohol-related cerebrocortical damage. Review of his cerebral CT showed global atrophy, suggesting the possibility of repeated traumatic injury in the past.
2 weeks after admission, his activities of daily living had improved to the point where he was considered suitable for placement in the rehabilitation hostel level.
His younger brother, Carl Philip Emmanuel Bach, a 46 year old male on sickness benefits, was brought in by ambulance with a 3 day history of being essentially bed-bound; unable to walk, he had been crawling to the bathroom and showered sitting on the floor. He was currently drinking about 300g-400g alcohol/day, and had been admitted to hospital on several occasions for alcohol withdrawal-related seizures.
Hypotheses for his inability to walk included cerebellar disease, Wernicke’s and alcohol-and malnutrition-related muscle wasting.
On examination, he had profound truncal and gait ataxia, pronounced scanning dystharthria, and symmetrical vertical and horizontal nystagmus; dysmetria (finger-nose past-pointing), dysdiadochokinesia and heel-shin ataxia. Limb muscle power, tone and reflexes were normal but there were diminished light touch sensation in the hands, and diminished light touch and pin-prick sensation and proprioception in the feet.
Investigations: he had negative serology for HIV, and screen for a range of neuronal antibodies was negative; cerebral CT was reported as showing generalised cerebral and cerebellar atrophy. There was no enhancement of the mamillary bodies with contrast (a radiological sign of necrosis at this site in Wernicke's disease). Electromyogram was consistent with moderate-severe peripheral neuropathy.
The diagnosis of alcoholic cerebellar degeneration, with severe midline and lateral cerebellar dysfunction, was made. After 4 months in the rehabilitation ward, he remained unsafe walking even with support, and hostel accommodation was required.
Ms PDQ Bach, 52 years old, was brought in by ambulance after falling down the stairs at home. She had been drinking daily since the age of 30. She had previously worked as an auditor but had been unable to work for the previous 4 years; she had been lately prone to leaving the house for a walk with the doors and windows wide open and no-one at home.
She was conscious and oriented with a Glasgow Coma Scale score of 16. There were marked hepatomegaly and cerebellar ataxia. She was incontinent of urine and faeces. LFTs showed alcoholic hepatitis. Cervical spine and cerebral CTs were normal.
The hypotheses for her fall were similar to those for her elder brother. She too was given oral thiamine 100mg and an alcohol withdrawal scale (AWS) was commenced, The AWS peaked at 6 on the 3rd day, and a total of 50mg of diazepam was given on this day, 60mg on the fourth day and the final AWS-determined dose of diazepam at lunch time on day 5, however PRN diazepam continued.
On the 6th day, PDQ’s gait remained unsteady and shuffling and she was mildly disoriented and belligerent, with a MMSE score of 23. She did not see why she should stay in hospital, though she could not walk safely, and was still incontinent of urine.
Hypotheses for her mental state included Wernicke’s, alcohol-related cerebrocortical damage, and the effects of continuing diazepam.
On the 15th day, the patient attempted to leave the hospital, wandering, confused, disoriented, paranoid and agitated. On psychiatric assessment, she was determined to have no perceptual disturbances or evidence of paranoia, but evidence of confabulation. The Mini Mental State Examination score was 21/30 with poor registration and recall, abstract thinking, sentence repetition and design. She was treated with haloperidol 5mg orally, and risperidone to begin 0.5mg orally bd; a 24 hour attendant was arranged under 'duty of care' provisions.
Formal neuropsychiatric testing later showed impaired cognition, delayed information recall with inclusion of intrusive and incorrect information, slow psychomotor function, including slow page scanning; reduced awareness and insight; deficits in cognitive and semantic fluency, visuo-spacial and visuo-constructional skills. These were said to be all consistent with alcoholic brain damage: further the memory problems were considered consistent with Korsakoff's syndrome.
Nine weeks after admission, the patient was still awaiting suitable placement.
In each of these cases, Dr Haber suggested thiamine should ideally have been given parenterally in the emergency department, rather than orally.
Written by Richard Hallinan FAChAM based on talk and power point presentation by Prof Paul Haber on Tuesday 20th April 2010 at Concord Hospital as part of the Concord Dependency Seminar Series. http://dependencyseminars.blogspot.com/
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Con Berbatis: May 2010 Pharmacy Research Events Practice Development
Dr John Dunlop (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA): Are Pharmacists their own worst enemy? | open full screen
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